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: 8 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

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)