Patient to Pharmacy Referral
Health care providers can download this template to refer appropriate patients to a pharmacy for vaccination.
Keep in mind, when using the pharmacy referral form:
- This form can also serve as an electronic prescription in some states.
- It is not designed to meet prescription requirements in every state, however, 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.
Vaccine Information Statements (VISs)
Vaccine Information Statements provide information for vaccine recipients, their parents, or their legal representatives. All VIS files are in .pdf format. They may be downloaded, printed, and used to make copies. Some VIS are available in audio and other language formats.
Additional CDC resources are available at
CDC, Centers for Disease Control and Prevention.