Notification of Immunization

Visiting Country
PATIENT’S PRIMARY DESTINATION

We recently provided immunization services to this patient. We want to make certain that you
have information about the vaccines or antibody product we administered to accommodate this
patient’s travel plan. Please contact us if you have any questions about this information.
We provided the patient (or parent/guardian) with a written record of the immunization(s) given.
We entered information about the immunization(s) we administered in the regional or state
immunization information system.

Patient’s name Patient’s birthdate

(MM/DD/YR)

(For a child, parent/guardian name Parent/guardian birthdate )

(MM/DD/YR)

The immunizations we administered on is/are checked below.

DATE

IMMUNIZATIONS ADMINISTERED
Influenza
COVID-19 Human papillomavirus (9vHPV)
BRAND
mRNA (circle one): Moderna Pfizer (Gardasil 9)
DOSE (mL)
Novavax MMR (MMR II, Priorix)
ROUTE (circle one): IM Nasal
Hepatitis B Varicella (chickenpox) (Varivax)
IPV (Polio)
Engerix-B; Recombivax HB; MMRV (ProQuad)
DOSE (circle one): 0.5 mL 1.0 mL Pneumococcal conjugate (PCV)
Hepatitis A (Havrix; Vaqta)
Heplisav-B (age 18 yrs and older) PCV13, Prevnar 13 DOSE (circle one): 0.5 mL 1.0 mL
PreHevbrio (age 18 yrs and older) PCV15, Vaxneuvance
HepA-HepB (Twinrix) (age 18yrs+)
PCV20, Prevnar 20
DTaP (age 6 yrs and younger)
Meningococcal ACWY (MenACWY)/
DTaP-HepB-IPV (Pediarix) Pneumococcal polysaccharide
(PPSV23) (Pneumovax 23) Meningococcal
DTaP-IPV (Kinrix, Quadracel)
DTaP-IPV/Hib (Pentacel) Respiratory Syncytial Virus (RSV) BRAND : ____________________

DTaP-IPV-Hib-HepB (Vaxelis) Abrysvo (Pfizer) DOSE (ML) : ____________________

Tdap (age 7 yrs and older) Arexvy (GSK)

BATCH NO : ____________________
Td (age 7 yrs and older) RSV Monoclonal Antibody
ROUTE : ____________________
Nirsevimab (Beyfortus)
Hib (monovalent) VALID UNTIL : _____________________
ActHIB (PRP-T) Rotavirus
Hiberix (PRP-T) RV1 (Rotarix)

NAME OF CLINIC PROVIDING SERVICES VACCINATOR

ADDRESS EMAIL ADDRESS

CITY/STATE/ZIP PHONE

Klinik Putra Simpang Ampat

Reference No :
www.klinikputrasimpangampat.com.my