A pharmacist who engages in the administration of vaccines shall, for a minimum of 4 years, keep a patient consent form that includes the:

1. (a) Name and date of birth of the patient;
2. (b) Name of the vaccine, manufacturer, lot number, and expiration date of the vaccine;
3. (c) Indication that the patient understands there are risks and possible side effects of the vaccine;
4. (d) Date of administration;
5. (e) Vaccine administrator’s name;
6. (f) Name of pharmacist overseeing the administration by pharmacy interns, licensed advanced pharmacy technicians, or pharmacy technicians as authorized by RSA 318:16-b; and
7. (g) Signature of the patient.

Source. #9552, eff 9-23-09; ss by #10185, eff 9-18-12; ss by #13558, eff 4-12-23