Patient to Pharmacy Referral

Health care providers can download this template to refer appropriate patients to a pharmacy for vaccination.

Pharma Template Pharma Template

Patient Referral to Pharmacy Template

Pharma TemplatePreview

Keep in mind, when using the pharmacy referral form:

  • This form can also serve as an electronic prescription in some states.
  • However, it is not designed to meet the prescription requirements in every state as these requirements vary. Please check the requirements in your state prior to utilizing this form as a prescription.
  • After patient vaccination, the pharmacist may add the vaccine-specific information and fax it back to you enabling you to update your patient's record.
  • State regulations regarding pharmacy vaccination differ, including whether a prescription is required. Check with the appropriate agency for the regulations in your state.
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VACC-1114133-0005 11/17