Vaccination Record
For individuals and families keeping their own immunization history in one place, and for small clinics that hand patients a written summary. It is a personal record; schools, employers and countries may require an official state or provider record.
- Fields
- 93
- Pages
- 1
- Paper
- Letter
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Reviewed
Before you start
What you need to fill it in
- Name and date of birth of the person vaccinated
- Vaccine names and dose numbers
- Date given, lot number and administering clinic
- Your state's immunization registry or provider printout, for checking
What's inside
93 fields, ready to fill
- 61Typed answersnames, addresses, descriptions
- 17Dateschecked as real dates
- 15Signaturessignature and initials
3 required — the editor counts down how many are left while you fill.
Instructions
How to fill out the Vaccination Record
- 1
Identify the person
Enter name and date of birth. Use one record per person.
- 2
Copy each vaccine
For each dose, enter the vaccine, dose number, date, lot number, site and provider from the clinic's record.
- 3
Add tests and exemptions
Note TB tests, titers or medical exemptions with dates in the notes.
- 4
Verify
Have a provider initial entries if you will use the record for school or travel, where accepted.
Fill it online
What filling it looks like
- Edit & fill, Invite to sign and Create form are three modes of the same editor
- Amounts are formula fields: they calculate as you type
- The field navigator counts what's left and jumps to the next field
Shown with our invoice template. Sample content; names are fictional.
Written for: Any
This template is a general starting point, not medical or legal advice. HIPAA, state privacy and consent rules vary; have your compliance lead or a qualified professional review it before use.
Written by PDFBetter and last reviewed October 15, 2026. Spotted a problem? Tell us.
Vaccination Record: questions people ask
Is this an official vaccination record?
No. It is a personal record. Schools, employers and travel authorities usually require a provider-signed record, a state registry printout or a specific state form.
Where can I find my official records?
Ask your doctor or pharmacy, or request a copy from your state immunization information system. Records from childhood may also be with school districts.
Can a provider sign this form?
Yes, there is a provider verification line. Whether a signed copy is accepted depends on who is asking for it.
How should I store it?
Keep the PDF in a safe place and consider protecting it with a password. Bring a printed copy when traveling.
Ready when you are
Fill the Vaccination Record now — no account to start.