Digital Vaccines & Supplies Order Form

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, I confirm

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.

Name(Required)

Health Care Provider / Facility Name:

Date(Required)

Contact Name:(Required)

Phone Number:(Required)

Email:(Required)

Fax:(Required)

Street Address:(Required)

City:(Required)

Postal Code:(Required)

Which vaccines would you like to order?

Check all that apply:(Required)

General Vaccines

Grade 7 School Immunization Program Vaccines

High Risk/Special Order Vaccines

RSV Vaccines & Immunizations

COVID-19 Vaccines

Influenza Vaccines

General Vaccines

Check off the vaccines you would like to order:

General List 1

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®)

General 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®)

General List 3

Td (Td Adsorbed®)

Tdap (Adacel® / Boostrix®)

Tdap-IPV (Adacel®-Polio)

Varicella (Varivax® III / Varilrix®)

Herpes Zoster (Shingrix®)

Note: As of June 2026, Ontario replaced the routine 12-month dose of meningococcal C conjugate vaccine (Men-C-C) with meningococcal ACYW conjugate vaccine (Men-C-ACYW).

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 (Imovax® Polio) doses on hand(Required)

# of IPV (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)

MMR (M-M-R® II / Priorix®)

# of MMR (M-M-R® II / Priorix®) doses on hand(Required)

# of MMR (M-M-R® II / Priorix®) 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®)

# 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 (Adsorbed®) doses on hand(Required)

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

Tdap (Adacel® / Boostrix®)

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

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

Tdap-IPV (Adacel®-Polio)

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

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

Varicella (Varivax® III / Varilrix®)

# of Varicella (Varivax® III / Varilrix®) doses on hand(Required)

# of Varicella (Varivax® III / Varilrix®) doses ordered(Required)

Herpes Zoster (Shingrix®)

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

# of Herpes Zoster (Shingrix®) doses ordered(Required)

School (Grade 7 Vaccine Program)

Check off the vaccines you would like to order:

School (Grade 7 Vaccine Program) Vaccines

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

Hepatitis B (Recombivax HB® / Engerix-B®)

HPV-9 (Gardasil® 9)

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)

Hepatitis B (Recombivax HB® / Engerix-B®)

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

# of Hepatitis B (Recombivax HB® / Engerix-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)

High Risk/Special Order Vaccines

Complete one order form per patient. Check off the vaccines you would like to order:

Patient Initials:(Required)

Patient DOB:(Required)

High Risk/Special Order Vaccines List 1

Hepatitis A – Adult (Havrix® or Vaqta®)

Hepatitis A – Pediatric (Havrix® or Vaqta®)

Hepatitis B – Adult (Engerix-B® / Recombivax HB®)

Hepatitis B – Pediatric (Engerix-B® / Recombivax HB®)

Hepatitis B – Renal, 40 mcg (Engerix-B®/(Engerix-B® / Recombivax HB®))

Hib (Act-HIB®)

High Risk/Special Order Vaccines List 2

HPV 9 (Gardasil® 9)

IPV (Imovax® Polio) – high-risk schedule

4CMenB (Bexsero®)

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

Pneumococcal 20-valent conjugate vaccine (Pneu-C-20) (Prevnar 20®)

Hepatitis A – Adult (Havrix®)

# of Hepatitis A – Adult (Havrix® or Vaqta®) doses on hand(Required)

# of Hepatitis A – Adult (Havrix® or Vaqta®) doses ordered(Required)

Hepatitis A – Pediatric (Havrix®)

# of Hepatitis A – Pediatric (Havrix® or Vaqta®) doses on hand(Required)

# of Hepatitis A – Pediatric (Havrix® or Vaqta®) doses ordered(Required)

Hepatitis B – Adult (Engerix-B® / Recombivax HB®)

# of Hepatitis B – Adult (Engerix-B® / Recombivax HB®) doses on hand(Required)

# of Hepatitis B – Adult (Engerix-B® / Recombivax HB®) doses ordered(Required)

Hepatitis B – Pediatric (Engerix-B® / Recombivax HB®)

# of Hepatitis B – Pediatric (Engerix-B® / Recombivax HB®) doses on hand(Required)

# of Hepatitis B – Pediatric (Engerix-B® / Recombivax HB®) doses ordered(Required)

Hepatitis B – Renal, 40 mcg (Engerix-B® / Recombivax HB®)

# of Hepatitis B – Renal, 40 mcg (Engerix-B® / Recombivax HB®) doses on hand(Required)

# of Hepatitis B – Renal, 40 mcg (Engerix-B® / Recombivax HB®) doses ordered(Required)

Hib (Act-HIB®)

# of Hib (Act-HIB®) doses on hand(Required)

# of Hib (Act-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 (Imovax® Polio) doses on hand(Required)

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

4CMenB (Bexsero®)

# of 4CMenB (Bexsero®) doses on hand(Required)

# of 4CMenB (Bexsero®) 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)

Pneumococcal 20-valent conjugate vaccine (Pneu-C-20) (Prevnar 20®)

# of Pneumococcal 20-valent conjugate vaccine (Pneu-C-20) (Prevnar 20®) doses on hand(Required)

# of Pneumococcal 20-valent conjugate vaccine (Pneu-C-20) (Prevnar 20®) doses ordered(Required)

RSV Vaccines and Immunizations

Check off the vaccines you would like to order:

RSV Vaccines and Immunizations

Abrysvo® – pregnancy (32–36 weeks gestation; use at 28-31 weeks is off-label) and eligible older adults

Beyfortus® (50 mg) – infants weighing less than 5 kg

Beyfortus® (100 mg) – infants weighing 5 kg or greater

Arexvy® (100 mg) – eligible older adults

Abrysvo® – pregnancy (32–36 weeks gestation; use at 28-31 weeks is off-label) and eligible older adults

# of Abrysvo® doses on hand(Required)

# of Abrysvo® doses ordered(Required)

Beyfortus® (50 mg) – infants weighing less than 5 kg

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

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

Beyfortus® (100 mg) – infants weighing 5 kg or greater (50 mg)

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

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

Arexvy® – eligible older adults

# of Arexvy® doses on hand(Required)

# of Arexvy® doses ordered(Required)

Covid-19 Vaccines

Check off the vaccines you would like to order:

Note: Please review the Health Care Provider Advisory regarding the market withdrawal of the 2025–2026 COVID-19 LP.8.1 vaccine formulations. Please ensure that all affected products have been removed from your vaccine refrigerator and managed according to the instructions outlined in the advisory.

Covid-19 Vaccine List

Spikevax® – Omicron XFG formulation (Moderna)

Comirnaty® – Omicron XFG formulation (Pfizer-BioNTech)

Spikevax® – Omicron XFG formulation (Moderna)

# of Spikevax® – Omicron XFG formulation (Moderna) doses on hand(Required)

# of Spikevax® – Omicron XFG formulation (Moderna) doses ordered(Required)

Comirnaty® – Omicron XFG formulation (Pfizer-BioNTech)

# of Comirnaty® – Omicron XFG formulation (Pfizer-BioNTech) doses on hand(Required)

# of Comirnaty® – Omicron XFG formulation (Pfizer-BioNTech) doses ordered(Required)

Influenza Vaccines

Influenza Vaccines List

Fluviral® (MDV) – trivalent inactivated vaccine (TIV) – 6 months and older

Fluzone® (MDV & PFS) – trivalent inactivated vaccine (TIV) – 6 months and older

Flucelvax® (PFS) – – cell culture-based trivalent inactivated vaccine (IIV3-cc) – 6 months and older

Fluad® (PFS) – adjuvanted trivalent inactivated vaccine (TIV-adj) – 65 years and older

Fluzone® High-Dose (PFS) – high-dose trivalent inactivated vaccine (TIV-HD) – 65 years and older

Fluviral® (MDV) – trivalent inactivated vaccine (TIV) – 6 months and older

Fluviral® (MDV) – trivalent inactivated vaccine (TIV) – 6 months and older doses on hand(Required)

# of Fluviral® (MDV) – trivalent inactivated vaccine (TIV) – 6 months and older doses ordered(Required)

Fluzone® (MDV & PFS) – trivalent inactivated vaccine (TIV) – 6 months and older

# of Fluzone® (MDV & PFS) – trivalent inactivated vaccine (TIV) – 6 months and older doses on hand(Required)

# of Fluzone® (MDV & PFS) – trivalent inactivated vaccine (TIV) – 6 months and older doses ordered(Required)

Flucelvax® (PFS) – cell culture-based trivalent inactivated vaccine (IIV3-cc) – 6 months and older

# of Flucelvax® (PFS) – cell culture-based trivalent inactivated vaccine (IIV3-cc) – 6 months and older doses on hand(Required)

# of Flucelvax® (PFS) – cell culture-based trivalent inactivated vaccine (IIV3-cc) – 6 months and older doses ordered(Required)

Fluad® (PFS) – adjuvanted trivalent inactivated vaccine (TIV-adj) – 65 years and older

# of Fluad® (PFS) – adjuvanted trivalent inactivated vaccine (TIV-adj) – 65 years and older doses on hand(Required)

# of Fluad® (PFS) – adjuvanted trivalent inactivated vaccine (TIV-adj) – 65 years and older doses ordered(Required)

Fluzone® High-Dose (PFS) – high-dose trivalent inactivated vaccine (TIV-HD) – 65 years and older

# of Fluzone® High-Dose (PFS) – high-dose trivalent inactivated vaccine (TIV-HD) – 65 years and older doses on hand(Required)

# of Fluzone® High-Dose (PFS) – high-dose trivalent inactivated vaccine (TIV-HD) – 65 years and older doses ordered(Required)

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