Pharmacy Immunization Protocol

This template is all you need to create a collaborative practice agreement with a physician so you can begin giving vaccines. A protocol of this nature is required in many states, although it may go by different terms (like standing order or protocol).

 

Comes as a Word file so you can edit it for your site. 5 pages total.

 

Sections include:

• Eligible patients
• Pharmacist requirements
• Patient monitoring
• Reporting
• Physician review of administration
• Appendix A: Pharmacists authorized under the protocol
• Appendix B: Pharmacists with authorization revoked under the protocol

Each download allows for the copy and use of the form for one pharmacy permit.

NOTE: This form is intended as an aid only and Pharmacy Compliance Specialists, LLC, shall not be held liable for damages resulting from the use or misuse of this product.