Digital Vaccines & Supplies Order Form

This form is currently undergoing maintenance and updates. Please check back on the afternoon of Friday, September 25, 2026.

Additional immunization information and program updates can be found on our Medical Advisories and Updates webpage.

Vaccine orders are filled based on product availability. Lambton Public Health (LPH) reserves the right to adjust order quantities based on available vaccine supply. All vaccine orders must include a copy of the last 7 consecutive days of temperature logs, including the current date.

Please allow two business days for your order to be filled.

By submitting this order form, I verify on behalf of the practice that the following:

Vaccine refrigerators have maintained temperatures between +2°C and +8°C, with temperatures documented twice daily.
Accurate temperature logs are maintained on site until the next annual cold chain inspection and will be provided to Lambton Public Health (LPH) upon request.
A cold chain contingency plan is in place in the event of a power outage and/or cold chain incident, including access to appropriate vaccine coolers and temperature monitoring devices.
No more than a one-month supply of vaccine is stored in the refrigerator.
Any temperature excursions outside of +2°C to +8°C have been reported to LPH, and the practice has followed all recommendations provided by LPH regarding the use of affected vaccines.

Do you confirm the above information to be true?(Required)

Yes

Temperature Log

Please upload and submit your temperature log

Upload Fridge Temperatures(Required)

Max. file size: 64 MB.

Order Information

Please fill out all required fields.

Health Care Provider / Facility Name:(Required)

Date:(Required)

Contact Name:(Required)

Phone #:(Required)

Email:(Required)

Fax:

Street Address:(Required)

City:(Required)

Postal Code:(Required)

Which vaccines would you like to order?

Check all that apply(Required)

General/School

High Risk/Special

RSV Vaccines & Immunizations

Covid-19 Vaccines

Flu Vaccines

Vaccine Supplies

General and School Vaccines

Check off the vaccines you would like to order:

General and School Vaccines

DTap-IPV-HIB (Pentacel® / Infanrix-IPV-Hib®)

HPV-9 (Gardasil® 9)

IPV (Imovax® Polio) – routine schedule

Men-C-ACYW-135 (Nimenrix® / MenQuadfi® / Menveo®)

MMR (M-M-R® II / Priorix®)

Vaccine list 2

MMRV (Priorix-Tetra® / ProQuad®)

Pneu-C-15 (Vaxneuvance)

Pneu-C-21 (Capvaxive) Individuals ≥65 years of age

PPD (Tubersol)

Rotavirus (Rot-1) (Rotarix®)

Vaccine List 3

Td (Td Adsorbed®)

Tdap (Adacel® / Boostrix®)

Tdap-IPV (Adacel®-Polio)

Var (Varivax III/Varilrix)

Zoster (Shingrix)

DTap-IPV-Hib (Pentacel® / Infanrix-IPV-Hib®)

# of DTap-IPV-HIB (Pentacel® / Infanrix-IPV-Hib®) doses on hand(Required)

# of DTap-IPV-HIB (Pentacel® / Infanrix-IPV-Hib®) doses ordered(Required)

HPV-9 (Gardasil 9)

# of HPV-9 (Gardasil 9) doses on hand(Required)

# of HPV-9 (Gardasil 9) doses ordered(Required)

IPV (Imovax® Polio)

# of IPV <b>(Imovax® Polio) doses on hand(Required)

# of IPV <b>(Imovax® Polio) doses ordered(Required)

Men-C-ACYW-135 (Nimenrix® / MenQuadfi® / Menveo®)

# of Men-C-ACYW-135 (Nimenrix® / MenQuadfi® / Menveo®) doses on hand(Required)

# of Men-C-ACYW-135 (Nimenrix® / MenQuadfi® / Menveo®) doses ordered(Required)

IPV (Imovax Polio)

# of IPV (Imovax Polio) doses on hand(Required)

# of IPV (Imovax Polio) doses ordered(Required)

Men-C-ACYW-135 (Menactra/Nimenrix)

# of Men-C-ACYW-135 (Menactra/Nimenrix) doses on hand(Required)

# of Men-C-ACYW-135 (Menactra/Nimenrix) doses ordered(Required)

MMRV (Priorix-Tetra® / ProQuad®)

# of MMRV (Priorix-Tetra® / ProQuad®) doses on hand(Required)

# of MMRV (Priorix-Tetra® / ProQuad®) doses ordered(Required)

Pneu-C-15 (Vaxneuvance)

# of Pneu-C-15 (Vaxneuvance) doses on hand(Required)

# of Pneu-C-15 (Vaxneuvance) doses ordered(Required)

Pneu-C-21 (Capvaxive)

Individuals ≥65 years of age

# of Pneu-C-21 (Capvaxive) doses on hand(Required)

# of Pneu-C-21 (Capvaxive) doses ordered(Required)

PPD (Tubersol)

# of PPD (Tubersol) doses on hand(Required)

# of PPD (Tubersol) doses ordered(Required)

Rotavirus (Rot-1) (Rotarix®)

# of Rotavirus (Rot-1) (Rotarix®) doses on hand(Required)

# of Rotavirus (Rot-1) (Rotarix®) doses ordered(Required)

Td (Td Adsorbed®)

# of Td (Td Adsorbed®) doses on hand(Required)

# of Td (Td Adsorbed®) doses ordered(Required)

Tdap (Adacel)

# of Tdap (Adacel® / Boostrix®) doses on hand(Required)

# of Tdap (Adacel® / Boostrix®) of doses ordered(Required)

Tdap-IPV (Adacel®-Polio)

# of Tdap-IPV (Adacel®-Polio) of doses on hand(Required)

# of Tdap-IPV (Adacel®-Polio) doses ordered(Required)

Var (Varivax III/Varilrix)

# of Var (Varivax-III/Varilrix) doses on hand(Required)

# of Var (Varivax-III/Varilrix) doses ordered(Required)

Zoster (Shingrix)

# of Zoster (Shingrix) doses on hand(Required)

# Zoster (Shingrix) doses ordered(Required)

High Risk and Special Order Vaccines

High Risk and Special Vaccines
Hepatitis A (Havrix)
Hepatitis B (Engerix-B/ Recombivax)
Hib (Act-HIB)
HPV-9 (Gardasil 9)
IPV (Imovax Polio) (*high risk schedule)
4CMenB (Bexsero)
Men-C-ACYW-135 (Menveo/Menactra/Nimenrix)
Pneumococcal 20-Valent Conjugate Vaccine (Prevnar 20)

Hepatitis A (Havrix)

Variant(Required)
Adult
Paed
Renal

Patient Initials(Required)
First Inital Last Initial

DOB(Required)

# of Hepatitis A (Havrix) doses ordered(Required)
Please enter a number greater than or equal to 1.

Hepatitis B (Engerix-B/ Recombivax)

Variant
Adult
Paed
Renal