Epic Immunization/Vaccine Lot Manager Form

Use this form to submit a request to Epic Ambulatory for Immunization/Vaccine Lot Manager additions in Epic. You may enter up to 10 immunizations/vaccine requests per submission.

Your request will be completed within two weeks of receipt.

DO NOT include Protected Health Information (PHI) on this form or attachment.

By checking this box, I am verifying that I am an Authorized Requestor in a manager/director role or a designated authorized requestor. *

Verified

Requestor's first name: *

Requestor's last name: *

Requestor's phone number: *

Requestor's Practice or Department: *

Lot: *

Immunization Type: *

Other Immunization Type: *

Manufacturer: *

Other Manufacturer: *

NDC on syringe or vial: *

Expiration Date: * +

Product (Vaccine Brand Name): *

Add another vaccine? *

Lot2: *

Immunization Type2: *

Other Immunization Type2: *

Manufacturer2: *

Other Manufacturer2: *

NDC on syringe or vial2: *

Expiration Date2: * +

Product (Vaccine Brand Name)2: *

Add another vaccine2? *

Lot3: *

Immunization Type3: *

Other Immunization Type3: *

Manufacturer3: *

Other Manufacturer3: *

NDC on syringe or vial3: *

Expiration Date3: * +

Product (Vaccine Brand Name)3: *

Add another vaccine3? *

Lot4: *

Immunization Type4: *

Other Immunization Type4: *

Manufacturer4: *

Other Manufacturer4: *

NDC on syringe or vial4: *

Expiration Date4: * +

Product (Vaccine Brand Name)4: *

Add another vaccine4? *

Lot5: *

Immunization Type5: *

Other Immunization Type5: *

Manufacturer5: *

Other Manufacturer5: *

NDC on syringe or vial5: *

Expiration Date5: * +

Product (Vaccine Brand Name)5: *

Add another vaccine5? *

Lot6: *

Immunization Type6: *

Other Immunization Type6: *

Manufacturer6: *

Other Manufacturer6: *

NDC on syringe or vial6: *

Expiration Date6: * +

Product (Vaccine Brand Name)6: *

Add another vaccine6? *

Lot7: *

Immunization Type7: *

Other Immunization Type7: *

Manufacturer7: *

Other Manufacturer7: *

NDC on syringe or vial7: *

Expiration Date7: * +

Product (Vaccine Brand Name)7: *

Add another vaccine7? *

Lot8: *

Immunization Type8: *

Other Immunization Type8: *

Manufacturer8: *

Other Manufacturer8: *

NDC on syringe or vial8: *

Expiration Date 8: * +

Product (Vaccine Brand Name)8: *

Add another vaccine8? *

Lot9: *

Immunization Type9: *

Other Immunization Type9: *

Manufacturer9: *

Other Manufacturer9: *

NDC on syringe or vial9: *

Expiration Date9: * +

Product (Vaccine Brand Name)9: *

Add another vaccine9? *

Lot10: *

Immunization Type10: *

Other Immunization Type10: *

Manufacturer10: *

Other Manufacturer10: *

NDC on syringe or vial10: *

Expiration Date10: * +

Product (Vaccine Brand Name)10: *

Attach scanned copy of Immunization Invoice: