Influenza/Pneumococcal Immunization Record

Site/Clinic Location: Influenza / pneumococcal Immunization Record Last Name First Name Initial Gender Provincial health Care Number/ULI Age Date of Birth (yyyy-Mon-dd). Alberta Address Phone (Home). City Province Postal Code Phone (Other). Out of Province Address (if applicable) Province Status: New to Alberta Visitor Influenza Vaccine Informed Consent Vaccine (Manufacturer): Priority List by Reason Code: Fluzone (SF) mL IM Lot # _____. 03 health care worker FluLaval (GSK) mL IM Lot # _____. Other _____ Lot # _____. 46 Pregnant women 02 65 years of age and older Site: Arm Left Right 45 6 months up to and including 23 months Leg Left Right 60 24 months up to and including 59 months 63 5 years up to and including 8 years of age For children requiring a 2nd dose: 64 9 years up to and including 64 years of age Next dose due on or after _____.

09826(Rev2018-06) Site/Clinic Location: Infl uenza/Pneumococcal Immunization Record Last Name First Name Initial Gender Provincial Health Care Number/ULI Age Date of Birth (yyyy-Mon-dd)

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  Health, Record, Immunization, Pneumococcal, Pneumococcal immunization record

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