Patient Referral to Pharmacy Template

Patient Referral to Pharmacy Template

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

This form can also serve as an electronic prescription
in some states. This form 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 vaccinating the patient, the pharmacist may add
the vaccine-specific information and fax it back to you
enabling you to update your patient's record.

Remember that state regulations regarding pharmacy
vaccination differ, including whether a prescription
is required. Check with the appropriate agency for
the regulations in your state.

VACC-1070804-0001 06/14