Fax: 519-885-7260. Phone: 519-575-4400 ext. 5505. 221687. Vaccine Order Form. â¢. Fax monthly temperature logs at the e
Routine Vaccine Order Form Fax monthly temperature logs at the end of every month Store only one month supply of vaccine Holding Point: WAT_WT______________________ Date: ___________ Phone: _______________ Facility Name: ______________________________ Contact Person:_________________________ Antigen(s)
Agent
Trade Name(s)
Tetanus, diphtheria, pertussis
Tdap
Adacel® / Boostrix®
Tetanus, diphtheria, pertussis, polio
Tdap-IPV
Adacel®-Polio / Boostrix®-Polio®
Measles, mumps, rubella
MMR
MMR® II / Priorix®
Measles, mumps, rubella, varicella
MMRV
Priorix-Tetra® / ProQuad®
Meningococcal Group C Conjugate
MenC-C
Menjugate Liquid®
Diphtheria, Tetanus, pertussis, polio, Hib
DTaP-IPV-Hib
Pediacel®
Pneumococcal polysaccharide
Pneu-P-23
Pneumococcal® 23
Pneumococcal Conjugate
Pneu-C-13
Prevnar 13®
Rotavirus
Rot-1
Rotarix®
Rot-5
Rotateq®
Tetanus, diphtheria *
Td
Td® Adsorbed
Varicella (chickenpox)
Var
Varivax® III / Varilrix®
Influenza
TIV High Dose
Fluzone High Dose ®
Influenza
QIV
FluLaval Tetra® / Fluzone®
Influenza
Q-LAIV
Flumist®
Haemophilus Influenzae B *
Hib
Act-Hib® / Hiberix®
Polio *
IPV
Imovax® Polio
Tuberculosis Skin Testing
Tuberculin
Tubersol®
Zoster
Zos
Zostavax®
# of Doses in stock
# of Doses needed
/ NeisVac-C®
*discretionary use only SPECIAL ORDERS: Complete appropriate order form for High Risk Hepatitis A, High Risk Hepatitis B, High Risk Meningococcal, High Risk HPV, School Program Vaccine, or Thermometers. Item Cards/Sleeves “Notify Public Health” tear off pad Log Book # Required
VACCINE ORDER FORMS AND RESOURCES ARE AVAILABLE ONLINE AT: bit.ly/vaccineresources Thank you for your support and commitment to improving the health of our community through immunization!
