PROVIDER INFORMATION Vaccine Provider: Clinic Site: Community Health Services Street Address: State Zip Code Street Address: State Zip Code Sabetha KS 66534 (Circle the appropriate vaccine, dose, extremity, site, route, and enter the manufacturer, lot #, and expiration date) FOR CLINICAL USE ONLY Mfr./Lot # Vaccine Dose Ext. Site Route VIS Date Exp. Date IM 0.25ml Sanofi Pasteur UH906AB 06/30/14 0.50ml U4694CA Private Inventory Deltoid RT UH908AA 1 2 7/26/2013 Vastus Lat Influenza UH907AA U4760AA LT Intranasal 11/25/13 Med Immune 0.2ml BH2174 VFC Inventory Sanofi Pasteur Influenza UH899AB IM 06/30/14 UH890AB 0.25ml U4694CA RT 0.50ml Deltoid U4694EA 7/26/2013 1 2 Vastus Lat UH890AB LT Intranasal UH898AB Med Immune 12/02/13 0.2ml BH2090 Pneumococcal Merck IM RT Deltoid H013847 03/15/14 1 2 10/06/2009 0.5ml J004747 LT Vastus Lat 07/20/14 ________ Date Signature and Title of Vaccine Administrator
PROVIDER INFORMATION Vaccine Provider: Community Health Services Clinic Site: Street Address: Sabetha State KS Zip Code 66534 Street Address: State Zip Code (Circle the appropriate vaccine, dose, extremity, site, route, and enter the manufacturer, lot #, and expiration date) FOR CLINICAL USE ONLY Vaccine Dose Ext. Site Route VIS Date Mfr./Lot # Exp. Date Private Inventory Influenza 1 2 RT LT Deltoid Vastus Lat IM 0.25ml 0.50ml Intranasal 0.2ml 7/26/2013 Sanofi Pasteur UH906AB U4694CA UH908AA UH907AA U4760AA Med Immune BH2174 06/30/14 11/25/13 VFC Inventory Influenza 1 2 RT LT Deltoid Vastus Lat IM 0.25ml 0.50ml Intranasal 0.2ml 7/26/2013 Sanofi Pasteur UH899AB UH890AB U4694CA U4694EA UH890AB UH898AB Med Immune BH2090 06/30/14 12/02/13 Pneumococcal 1 2 RT LT Deltoid Vastus Lat IM 0.5ml 10/06/2009 Merck H013847 J004747 03/15/14 07/20/14 ________ Signature and Title of Vaccine Administrator Date
Flu%20Consent%20Form2013-14.docx