Pediatric Immunization Record
Child's Name
Date of Birth
Parent/Guardian Name
Contact Number
Address
Vaccine
Date Given
Lot Number
Administered By
Notes
DTP (Diphtheria, Tetanus, Pertussis)
Polio
MMR (Measles, Mumps, Rubella)
Hepatitis B
Varicella (Chickenpox)
Hib (Haemophilus influenzae type b)
Pneumococcal
Rotavirus
Influenza
Other
Additional Notes