The completion of this form is necessary for every vaccine ...

VIS Date VIS . Given IIV4. Fluzone Quadrivalent Sanofi Pasteur 0.25. 0.5 Yes. No Yes. No IM R Arm L Arm. R Leg L Leg August 7 2015 Fluzone High Dose (IIV3-HD) Sanofi Pasteur 0.5 No Yes IM R Arm. L Arm August 7 2015 Signature of Vaccine Administrator: _____ 2018-2019 Flu Insurance Information Form . Provider Name: ................
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