vaccination ONLY OFFICE TO COMPLETE BELOW GRITS DATA ENTRY FOR INTEGRATION WITH OFFICE ALLYPatient Last Name: Patient First Name: Verified In Grits? Yes NoVerified By Date Receiving today: 1st 2nd Booster Moderna Pfizer Johnson and Johnson OtherDate of Vaccination: Name of Vaccine: Site-Deltoid : Right OR LeftDose: Lot Number: Exp Date of Vaccine: Who Administered Vaccine: Was Vaccine Information Sheet (Vis) Information Given: Yes NoTime Vaccine Given: Time Observation Ends: Adverse Reactions: Observed By: Submit Form
