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Immunization Signature Form (Indiana)

This creates a parent/guardian signature form for a patient's immunization record. You must search for a patient first.

Create the Form

To create this form, click the Reports > State Reports > Immunization Signature Form > Menu link. The Vaccine Administration Patient Record page opens.  Enter the criteria and click Create Form. The form displays in a separate browser tab and can be printed using the browser's print function.

Follow the instructions on the Vaccine Administration Patient Record for capturing a signature. See Electronic Signature Software Setup for instructions on setting up the software to use the SignatureGem Electronic Signature Pad.

The available form criteria fields are as follows:

Field Description

Complete for Report Date

Enter the date for the report. The default is the current date.

Page 1

Page 1 is automatically selected, but Page 2 can be selected instead, when ready.

Vaccinations Requested

Select all of the applicable vaccinations to include on the form.

Responsible Adult

Select the person who will be signing the form (i.e., Mother, Father), or select Other and enter the category/description (i.e., Guardian).

Other Phone Number

Enter the work or other phone number. If this is an "other" phone number, enter a description (i.e., Brother's cell phone).

Page 2

Select this option when ready to display and print Page 2.

Example Report

The following image is of an example Patient Record form:

Example Immunization Signature Form (Page 2) for Indiana

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