Digital Vaccines & Vaccine 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

Covid-19

RSV Vaccines

Flu

Vaccine Supplies

General and School Vaccines

Check off the vaccines you would like to order

General and School Vaccines

DTap-IPV-HIB (Pediacel)

Hepatitis B (Recombviax HB/Engerix-B)

Hepatitis B Paed (Recombviax HB/Engerix-B)

HPV-9 (Gardasil 9)

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-13 (Prevnar 13)

Pneu-P-23 (Pneumovax 23)

PPD (Tubersol)

Vaccine List 3

Rotavirus-1 (Rotarix)

Td (Adsorbed)

Tdap (Adacel)

Tdap-IPV (Adacel-Polio)

Var (Varivax III/Varilrix)

Zoster (Shingrix)

DTap-IPV-Hib (Pediacel)

Catalogue #6571-3346-0 (5 per box)

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

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

Hepatitis B (Recombviax HB/Engerix-B)

Catalogue #6571-3243-0 (1 per box)

# 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)

Catalogue #6571-3251-0 (1 per box)

# 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)

Catalogue #6571-3390-0 (1 per box)

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

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

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

Catalogue #6571-3370-1 (10 per box)

# 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)

Catalogue #6571-3344-3 (10 per box)

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

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

MMR (MMR-II/Priorix)

Catalogue #6571-3230-0 (10 per box)

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

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

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

Catalogue #6571-3604-0 (10 per box)

# 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-13 (Prevnar 13)

Catalogue #6571-2202-5 (10 per box)

# of Pneu-C-13 (Prevnar 13) doses on hand(Required)

# of Pneu-C-13 (Prevnar 13) doses ordered(Required)

Pneu-P-23 (Pneumovax 23)

Catalogue #6571-4010-2 (10 per box)

# of Pneu-P-23 (Pneumovax 23) doses on hand(Required)

# of Pneu-P-23 (Pneumovax 23) doses ordered(Required)

PPD (Tubersol)

Catalogue #6506-3311-0 (10/multi-dose vial)

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

# of PPD (Tubersol) doses ordered(Required)

Rotavirus-1 (Rotarix)

Catalogue #6571-4233-0 (10 per box)

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

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

Td (Adsorbed)

Catalogue #6571-3240-0 (5 per box)

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

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

Tdap (Adacel)

Catalogue #6571-2203-0 (5 per box)

# of Tdap (Adacel) on hand(Required)

# of Tdap (Adacel) of doses ordered(Required)

Tdap-IPV (Adacel-Polio)

Catalogue #6571-2013-1 (10 per box)

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

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

Var (Varivax III/Varilrix)

Catalogue #6571-3305-0 (10 per box)

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

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

Zoster (Shingrix)

Catalogue #6571-2020-0 (1 per box)

# 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)

4CMenB (Bexsero)

Men-C-ACYW-135 (Menveo/Menacta/Nimenrix)

Hepatitis A (Havrix)

Catalogue #6571-3257-0 (ADULT) (1 per box)
Catalogue #6571-3256-0 (paed) (1 per box)

Variant(Required)

Adult

Paed

Renal

Patient Initials(Required)

First Inital Last Initial

DOB(Required)

Hepatitis A (Havrix) Dose #(Required)

# of Hepatitis A (Havrix) Doses Required(Required)

Hepatitis B (Engerix-B/ Recombivax)

Catalogue #6571-3243-0 (ADULT/adolescent) (1 per box)
Catalogue #6571-3252-0 (paed) (1 per box)
Catalogue #6571-3324-1 (renal-40 mcg) (1 per box)

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 Required(Required)

Hib (Act-HIB)

Catalogue #6571-3243-0 (ADULT/adolescent) (1 per box)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

Hib (Act-HIB) Dose #(Required)

# of Hib (Act-HIB) Doses Required(Required)

HPV-9 (Gardasil 9)

Catalogue #6571-3390-0 (ADULT/adolescent) (1 per box)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

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

# of HPV-9 (Gardasil 9) Doses Required(Required)

IPV (Imovax Polio)

Catalogue #6571-3220-2(1 per box))

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

IPV (Imovax Polio) Dose #(Required)

# of IPV (Imovax Polio) Doses Required(Required)

4CMenB (Bexsero)

Catalogue #6571-3314-0 (1 per box)

Patient Initials(Required)

First Initial Last Initial

DOB(Required)

4CMenB (Bexsero) Dose #(Required)

# of 4CMenB (Bexsero) Doses Required(Required)

Men-C-ACYW-135 (Menveo)

Catalogue #6571-2017-0 (1 per box)

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 Required(Required)

Covid 19 Vaccines

To receive COVID-19 vaccine, your office must be an approved COVID-19 vaccine site and ensure the following criteria are met(Required)

Providers at your site have obtained a COVaxON ID and completed training via OntarioMD

Available Vaccines(Required)

Moderna [SPIKEVAX]™ XBB.1.5

Pfizer® COMIRNATY (Omicron XBB.1.5 – Adult)

Pfizer® COMIRNATY (Omicron XBB.1.5 – Pediatric)

Novavax NUVAXOVID™ XBB.1.5

Moderna [SPIKEVAX]™ XBB.1.5

Number of 0.5 mL doses (12+): 5
Number of 0.25 mL doses (6m – 11y): 10

# of Moderna [SPIKEVAX]™ XBB.1.5 Doses on Hand(Required)

# of Moderna [SPIKEVAX]™ XBB.1.5 Doses Required(Required)

Pfizer COMIRNATY (Omicron XBB.1.5 – Adult)

Number of 0.3 mLdoses (12+) per vial: 6
Grey cap on vial

# of Pfizer COMIRNATY (Omicron XBB.1.5 – Adult) Doses on Hand(Required)

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

Pfizer COMIRNATY (Omicron XBB.1.5 – Pediatric)

Number of 0.3 mLdoses (5-<12y) per vial: 6
Blue cap on vial

# of Pfizer COMIRNATY (Omicron XBB.1.5 – Pediatric) Doses on Hand(Required)

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

Novavax NUVAXOVID™ XBB.1.5

Number of 0.5 mL doses (12+) per vial: 5

# of Novavax NUVAXOVID™ XBB.1.5 Doses on Hand(Required)

# of Novavax NUVAXOVID™ XBB.1.5 Doses Required(Required)

RSV Vaccines

AREXVY should only be reconstituted with the accompanying adjuvant suspension containing Respiratory Syncytial Virus PreF3 (RSVPreF3) glycoprotein F antigen.

RSV Vaccines

AREXVY

AREXVY Eligibility:

Patient must be 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

Catalogue #6571-2300-0

# of AREXVY Doses on Hand(Required)

# of AREXVY Doses Required(Required)

Flu Vaccines

Flu Vaccines(Required)

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

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

Fluzone® High-Dose Quadrivalent (PFS) High-Dose Quadrivalent Inactivated Vaccine (High Dose QIV) (65 years and older)

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

3 of Fluzone® Quadrivalent (MDV) FluLaval Tetra® (PFS) Quadrivalent Inactivated Vaccine (QIV) Doses on Hand(Required)

# of Fluzone® Quadrivalent (MDV) FluLaval Tetra® (PFS) Quadrivalent Inactivated Vaccine (QIV) Doses Required(Required)

Fluad® (PFS)

Adjuvanted Trivalent Inactivated Vaccine (TIV-adj)

# of Fluad® (PFS) Doses on Hand(Required)

3 of Fluad® (PFS) Doses Required(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 Required(Required)

Additional supplies you would like to order

Supplies
Immunization Card (English)
Min-Max Thermometer
Poster: Immunization Through the Lifespan (English)
Sticker: Do Not Unplug
Sticker: How to Monitor Your Refrigerator Temperature
Sticker: Protect Your Vaccines – Protect Your Patients
Sticker: STOP!
Sticker: This Cooler Contains Perishable Vaccines DO NOT FREEZE
Vaccine Refrigerator Maintenance Logbook (English)
Vaccine Storage and Handling Guidelines Booklet (English)

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.