HCP New Vaccine Site Application Form

New Vaccine Site Application

Use this form if you are a facility or healthcare provider who will need to order vaccines and other publicly-funded medical supplies. If you are ordering vaccines, a site inspection will be required prior to being eligible to order these products. Complete ALL fields to avoid a delay in processing your application.

Application Type(Required)

New Application

Change Existing Record

Other

If other, please specify(Required)

Family/Health Care Provider Information(Required)

Single Provider

Group Provider

Provide all Associated Doctor Names (Press + to add line for additional names)(Required)

Please Provide Physician Name(Required)

Type of Facility/ Health Care Provider(Required)

Pediatrician, Solo (individual fridge)

Paediatrician, Group (shared fridge)

Family Physician, Individual (individual fridge)

Family Physician, Group (shared fridge)

Family Health Team

Long Term Care Home

Pharmacy

Other

If other, please specify(Required)

Contact Information

Main Contact (first and last name):(Required)

Secondary Contact (first and last name):

Telephone:(Required)

Secondary Telephone:

Email:(Required)

Fax:

Address (Street No. / Street Name):(Required)

Unit No:

PO Box (STN / RPO / RR):

Postal Code:(Required)

City/Town:(Required)

Note about Vaccine Orders

Note About Vaccines Orders

Vaccine sites must have a monitored refrigerator for vaccine storage that has been inspected by the health unit. To begin receiving vaccines, a copy of seven consecutive days of fridge temperatures are required between 2-8 degrees celsius.

Product Ordering

Products you will be ordering (check all that apply)(Required)

General Vaccines (other than Influenza, High-Risk or COVID-19)

COVID-19 Vaccines

Influenza

High-Risk Vaccines

Supplies

Other

If other, please specify:(Required)