Influenza PCV13 PPSV23 HPV Tdap VZV Other Patient Name Manufacturer/ Manufacturer/ Manufacturer/ Manufacturer/ Manufacturer/ Manufacturer/ Manufacturer/ and DOB Lot Number/ Lot Number/ Lot Number/ Lot Number/ Lot Number/ Lot Number/ Lot Number/ Expiration Expiration Expiration Expiration Expiration Expiration Expiration NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: Source: AMA. Practice transformation series: implementing a team-based adult immunization program. 2017.
Patient Name and DOB Influenza Manufacturer/ Lot Number/ Expiration PCV13 Manufacturer/ Lot Number/ Expiration PPSV23 Manufacturer/ Lot Number/ Expiration HPV Manufacturer/ Lot Number/ Expiration Tdap Manufacturer/ Lot Number/ Expiration VZV Manufacturer/ Lot Number/ Expiration Other Manufacturer/ Lot Number/ Expiration NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: NAME: DOB: VIS Edition & Date Given: Source: AMA. Practice transformation series: implementing a team-based adult immunization program. 2017.
10.1001stepsforward.2017.0001supp5.docx