Pediatric Immunization Record Last name First Date of birth // Mother s maiden name Vaccine Diphtheria Tetanus Pertussis Date given1 MO/DAY/YR Type of vaccine Mftr1 see back Lot 1 M. Patient behind schedule Flag the record if the patient is behind on recommended immunizations. Record type of vaccine Be sure to indicate the type of vaccine you gave. This is especially important when you give DT-pediatric rather than DTaP since children who receive...
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