Child and Teen Immunization Record Card - Free Download
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Type of Date given Healthcare professional Date next
vaccine mo/day/yr or clinic dose due
(mo.) (day) (yr.)
CHILD & TEEN IMMUNIZATION RECORD
Always carry this record with you and have your
healthcare professional or clinic keep it up to date.
Last name First name M.I.
Printed by Immunization Action Coalition, Saint Paul, MN
www.immunize.org • www.vaccineinformation.org
Medical notes (e.g., allergies, vaccine reactions):
Healthcare provider: List the mo/day/yr for each vaccination given. Record the
generic abbreviation (e.g., PCV13, DTaP-HepB-IPV) or the trade name. For
combination vaccines, ﬁll in a row for each separate antigen in the combination.
Item #R2003 (9/10)
(DTaP, DTP, DT,
To learn more about vaccines, visit www.immunize.org or www.vaccineinformation.org