Digital Vaccines & Supplies Order Form

Vaccines & Vaccine Supplies Order Form

Vaccines will be distributed based on availability. We reserve the right to make changes to your order. All vaccine orders require a copy of last 7 consecutive days temperature log including the current date and two business days to fill order.

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

• Refrigerators have maintained temperatures between +2°C to +8°C and temperatures are documented twice daily
• Accurate temperature logs will be provided upon request and are kept on site until our next annual cold chain inspection
• A contingency plan is in place should a power outage and/or cold chain incident occur, including vaccine coolers temperature monitoring devices
• No more than one month supply is kept in the refrigerator
• All temperature excursions outside of +2°C to +8°C (if applicable) have been reported to Lambton Public Health and recommendations regarding usage of the affected vaccines have been implemented by the practice

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

Yes

Temperature Log

Please upload and submit your temperature log

Upload Fridge Temperatures(Required)

Drop files here or

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)

Province:(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)

Hepatitis B (Recombviax HB/Engerix-B)

Hepatitis B Paed (Recombviax HB/Engerix-B)

HPV-9 (Gardasil 9)

IPV (Imovax Polio) (*routine schedule)

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

Vaccine list 2

Men-C-C (Menjugate/NeisVac-C)

MMR (MMR-II/Priorix)

MMR-VAR (Priorix-Tetra/Pro-Quad)

Pneu-C-15 (Vaxneuvance)

Pneu-C-20 (Prevnar 20)

PPD (Tubersol)

Vaccine List 3

Rotavirus-1 (Rotarix)

Td (Adsorbed)

Tdap (Adacel)

Tdap-IPV (Adacel-Polio)

Var (Varivax III/Varilrix)

Zoster (Shingrix)

Vaccine Program Table

Note: The Ministry of Health is transitioning to two new pneumococcal vaccines which will now be used in the publicly funded program. Pneu-C-13 (Prevnar-13) and Pneu-P-23 (Pneumovax) are discontinued. Please return any unused product. See the table below to ensure you are ordering the correct new vaccine.

Vaccine Program	Eligible Age Group	Previous Vaccine	Current Vaccine
Routine	6 weeks to 4 years of age	Pneu-C-13	Pneu-C-15 Vaxneuvance
Routine	≥65 years of age	Pneu-P-23	Pneu-C-20 Prevnar 20
High Risk	≥6 weeks of age and older	Pneu-P-23 and Pneu-C-13	Pneu-C-20 Prevnar 20

Important Prevnar 20 Storage Requirements: Syringes should be stored horizontally (laying flat on shelf) to minimize the re-dispersion time. Do not use the vaccine if it cannot be re-suspended. Do not use if large particulate matter or discoloration is found. For more information about Prevnar 20 storage, handling, and administration, please refer to the product monograph.

DTap-IPV-Hib (Pentacel)

# of DTap-IPV-HIB (Pentacel) doses on hand(Required)

# of DTap-IPV-HIB (Pentacel) doses ordered(Required)

Hepatitis B (Recombviax HB/Engerix-B)

# of Hepatitis B (Recombviax HB/Engerix-B) doses on hand(Required)

# of Hepatitis B (Recombviax HB/Engerix-B) doses ordered(Required)

Hepatitis B Paed (Recombivax HB/Engergix-B)

# of Hepatitis B Paed (Recombivax HB/Engergix-B) doses on hand(Required)

# of Hepatitis B Paed (Recombivax HB/Engergix-B) 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 (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/NeisVac) doses on hand(Required)

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

Men-C-C (Menjugate/NeisVac-C)

# of Men-C-C (Menjugate/NeisVac) doses on hand(Required)

# of Men-C-C (Menjugate/NeisVac) doses ordered(Required)

MMR (MMR-II/Priorix)

# of MMR (MMR-11/Priorix) doses on hand(Required)

# of MMR (MMR-11/Priorix) doses ordered(Required)

MMR-VAR (Priorix-Tetra/Pro-Quad)

# of MMR-VAR (MMR/Priorix-Tetra/Pro-Quad) doses on hand(Required)

# of MMR-VAR (MMR/Priorix-Tetra/Pro-Quad) 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-20 (Prevnar 20)

# of Pneu-C-20 (Prevnar 20) doses on hand(Required)

# of Pneu-C-20 (Prevnar 20) doses ordered(Required)

PPD (Tubersol)

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

# of PPD (Tubersol) doses ordered(Required)

Rotavirus-1 (Rotarix)

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

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

Td (Adsorbed)

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

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

Tdap (Adacel)

# of Tdap (Adacel) doses on hand(Required)

# of Tdap (Adacel) 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/Menacta/Nimenrix)

Hepatitis A (Havrix)

Variant(Required)

Adult

Paed

Renal

Patient Initials(Required)

First Inital Last Initial

DOB(Required)

Hepatitis A (Havrix) Dose #(Required)

# of Hepatitis A (Havrix) doses ordered(Required)

Hepatitis B (Engerix-B/ Recombivax)

Variant

Adult

Paed

Renal

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

Hepatitis B (Engerix-B/ Recombivax) Dose #(Required)

# of Hepatitis B (Engerix-B/ Recombivax) doses ordered(Required)

Hib (Act-HIB)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

Hib (Act-HIB) Dose #(Required)

# of Hib (Act-HIB) doses ordered(Required)

HPV-9 (Gardasil 9)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

HPV-9 (Gardasil 9) Dose #(Required)

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

IPV (Imovax Polio)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

IPV (Imovax Polio) Dose #(Required)

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

4CMenB (Bexsero)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

4CMenB (Bexsero) Dose #(Required)

# of 4CMenB (Bexsero) doses ordered(Required)

Men-C-ACYW-135 (Menveo)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

4CMenB (Bexsero) Men-C-ACYW-135 (Menveo) Dose #(Required)

# of 4CMenB (Bexsero) Men-C-ACYW-135 (Menveo) doses ordered(Required)

Covid 19 Vaccines

Available Vaccines(Required)

Moderna SPIKEVAX KP.2 COVID-19 mRNA Vaccine

Pfizer COMIRNATY KP.2 COVID-19 mRNA Vaccine

See the Ministry of Health COVID-19 Vaccine Program website for more information about eligibility.
See Moderna’s website for health care professionals.
See Pfizer’s website for health care professionals.

# of Moderna SPIKEVAX KP.2 COVID-19 mRNA doses on hand(Required)

# of Moderna SPIKEVAX KP.2 COVID-19 mRNA doses ordered(Required)

# of Pfizer COMIRNATY KP.2 COVID-19 mRNA doses on hand(Required)

# of Pfizer COMIRNATY KP.2 COVID-19 mRNA doses ordered(Required)

Pfizer COMIRNATY (Omicron XBB.1.5 – Adult)

# of Pfizer COMIRNATY (Omicron XBB.1.5 – Adult) doses on hand(Required)

# of Pfizer COMIRNATY (Omicron XBB.1.5 – Adult) doses ordered(Required)

Pfizer COMIRNATY (Omicron XBB.1.5 – Pediatric)

# of Pfizer COMIRNATY (Omicron XBB.1.5 – Pediatric) doses on hand(Required)

#of Pfizer COMIRNATY (Omicron XBB.1.5 – Pediatric) doses ordered(Required)

Novavax NUVAXOVID™ XBB.1.5

# of Novavax NUVAXOVID™ XBB.1.5doses on hand(Required)

# of Novavax NUVAXOVID™ XBB.1.5 doses ordered(Required)

RSV Vaccines & Immunizations

RSV Vaccines

ABRYSVO

Beyfortus (50 mg) (Children weighing less than 5kg)

Beyfortus (100 mg) (Children weighing greater or equal to 5kg)

ABRYSVO Eligibility:

60 years of age and older and meet one of the following criteria:

1. Living in a long-term care home, Elder Care Lodge, and/or eligible retirement homes (homes licensed to provide dementia care)
2. Hospital alternate level of care (ALC) patients
3. Receiving hemodialysis or peritoneal dialysis
4. Recipients of solid organ or hematopoietic stem cell transplants
5. Experiencing homelessness
6. Indigenous, including those in urban dwellings

Pregnant residents of Ontario from 32 to 36 weeks gestational age who will deliver near the start of or during the 2024/25 RSV season.

NACI recommends Beyfortus as the preferred product to protect infants (available in October), so administration of Abrysvo to pregnant individuals should be on a case-by-case basis.

See the Ministry of Health RSV web page for more information prior to ordering.

# of ABRYSVO doses on hand(Required)

# of ABRYSVO doses ordered(Required)

Beyfortus Eligibility:

Born in 2024 prior to RSV Season
Born during the 2024/25 RSV Season
Children up to 24 months of age who remain vulnerable from severe RSV disease through their second RSV season
See the Ministry of Health RSV web page for more information prior to ordering.

Beyfortus (50 mg) (Children weighing less than 5kg)

# of Beyfortus (50 mg) doses on hand(Required)

# of Beyfortus (50 mg) doses ordered(Required)

Beyfortus (100 mg) (Children weighing greater or equal to 5kg))

# of Beyfortus (100 mg) doses on hand(Required)

# of Beyfortus (100 mg) doses ordered(Required)

Flu Vaccines

Flu Vaccines(Required)

Fluzone® Quadrivalent/FluLaval Tetra® (MDV) (Quadrivalent Inactivated Vaccine – QIV) (6 months and older)

Fluad® (PFS) (Adjuvanted Trivalent Inactivated Vaccine – TIV-adj) (65 years and older)

Fluzone® Quadrivalent/FluLaval Tetra® (MDV)

Quadrivalent Inactivated Vaccine – QIV (6 months and older)

# of Fluzone® Quadrivalent/FluLaval Tetra® (MDV) (Quadrivalent Inactivated Vaccine – QIV) doses on hand(Required)

# of Fluzone® Quadrivalent/FluLaval Tetra® (MDV) (Quadrivalent Inactivated Vaccine – QIV) doses ordered(Required)

Fluad® (PFS)

Adjuvanted Trivalent Inactivated Vaccine (TIV-adj)

# of Fluad® (PFS) doses on hand(Required)

# of Fluad® (PFS) doses ordered(Required)

Fluzone® High-Dose Quadrivalent (PFS)

High-Dose Quadrivalent Inactivated Vaccine (High Dose QIV)

# of Fluzone® High-Dose Quadrivalent (PFS) doses on hand(Required)

# of Fluzone® High-Dose Quadrivalent (PFS) doses ordered(Required)

Additional supplies you would like to order

Supplies

Supplies 2

Vaccine Temperature Logbook (English)

Vaccine Reporting Business Cards

Vaccine Promotion Poster

Get the Facts: The Human Papillomavirus (HPV) Poster

It’s Time to Talk Poster

HPV Poster

HPV Handout

Gardasil 9 Handout

Vaccine Cooler

Immunization Card (English)(Required)

Min-Max Thermometer(Required)

Poster: Immunization Through the Lifespan (English)(Required)

Sticker: DO NOT UNPLUG!(Required)

Sticker: How to Monitor Your Refrigerator Temperature(Required)

Sticker: Protect Your Vaccines – Protect Your Patients(Required)

Sticker: STOP!(Required)

Sticker: This Cooler Contains Perishable Vaccines DO NOT FREEZE(Required)

Vaccine Refrigerator Maintenance Logbook (English)(Required)

Vaccine Storage and Handling Guidelines Booklet (English)(Required)

Vaccine Temperature Logbook (English)(Required)

Vaccine Reporting Business Cards(Required)

Vaccine Promotion Poster(Required)

Get the Facts: The Human Papillomavirus (HPV) Poster(Required)

It’s Time to Talk Poster(Required)

HPV Poster(Required)

HPV Handout(Required)

Gardasil 9 Handout(Required)

Vaccine Cooler(Required)

The information in this form is being collected, used, and disclosed subject to the Health Protection and Promotion Act (Ontario) and the Personal Health Information Protection Act, 2004 (Ontario). Personal information contained on this form is collected for the purposes of vaccine ordering by Lambton Public Health. Any questions regarding the collection, use and disclosure of this information may be directed to Lambton Public Health at 519-383-8331 or toll free 1-800-667-1839.