GP Vaccine Return Form - HSE

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United Drug House, Magna Business Park, Citywest Road, Dublin 24. Registered in Ireland as United Drug plc. Company No.
HSE National Cold Chain Service United Drug House, Magna Business Park, Citywest Road, Dublin 24. Registered in Ireland as United Drug plc. Company No. 12244

GP Vaccine Return Form

Route Code: THIS FORM

SHOULD BE COMPLETED BY ANYONE RETURNING OUT OF DATE AND UNUSED VACCINES FOR DESTRUCTION.

ONLY UNUSED/UNOPENED HSE VACCINE IN ITS ORIGINAL PACKAGING CAN BE RETURNED WHICH MUST BE PLACED IN A RETURNS BOX.

NO SHARPS

ARE ACCEPTED.

NAME UD ACCOUNT NUMBER REASON FOR RETURNS DRIVERS SIGNATURE:

DATE OF RETURN COLLECTION

PLEASE

COMPLETE IN

FULL

VACCINE NAME

PRODUCT NAME

6 in 1

Infanrix Hexa

4 in 1

IPV-Infanrix Tetravac

Men C

Menjugate

PCV 13(Paediatric)

Prevenar 13

PCV (Paediatric)

Prevenar

MMR

MMR VAX Pro Priorix

Hib

Hiberix Act Hib

Td

Dite Booster

Influenza Vaccine Pneumococcal Polysaccharide Vaccine (PPV)

Pneumovax

Hepatitis B Adult

Engerix B HBVaxPro 10

Hepatitis B Paediatric

Engerix B Paed HBVaxPro 5

Others (please give details of each vaccine)

QUANTITY

BATCH NUMBER

EXPIRY DATE