Vaccine Return Form - Lambton Public Health

Please Be Advised

• Vaccines returns will NOT be accepted without a completed Vaccine Return Form
• Cold Chain does not need to be maintained for returned vaccines
• Returns must be placed in a paper or plastic bag. Loose returns will NOT be accepted.
• You do not need to return COVID-19 vaccines to LPH. Contact us for further direction.

Contact Information

Health Care Provider/Clinic Name:(Required)

Main Contact Name:(Required)

Telephone:(Required)

Email:(Required)

Date:(Required)

Fax:

Return Information

Name of Vaccine:(Required)

Lot #:(Required)

# Doses:(Required)

Reason(Required)

Would you like to return more vaccines?(Required)

Yes

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason

Name of Vaccine:

Lot #:

# Doses:

Reason