PROVIDER REQUEST FOR CHILDHOOD VACCINE SEASONAL INFLUENZA VACCINE 2011-2012 Provider PIN#: used last month and doses on hand for each vaccine, including vaccines not ordered, are required with every order For more information, see Immunization Guidelines for the Use of State-Supplied Vaccines at: SHIP TO: DATE ORDERED: Check If Any SHIPPING ADDRESS: Shipping Changes CITY: ZIP: CONTACT: TELEPHONE: FAX: DELIVERY TIMES: Monday Tuesday Wednesday Thursday Friday Please specify all days and hours your clinic is available to receive vaccine. (e.g., 9AM-3PM) Special Shipping Instructions (e.g., Closed for lunch 12-1): MUST COMPLETE ALL FIELDS BELOW* Vaccine Description / Guidelines for Use Minimum Number of Doses Used Doses On Order Last Month Hand (Doses) Ordered Fluzone® - Preservative free, 10x1 single dose pre-filled syringe (0.25mL) sanofi-pasteur Influenza 10 6 months of age up to the 3rd birthday Fluzone® - Multi-dose vial (5.0mL) sanofi-pasteur Influenza 10 3 years of age up to the 19th birthday FluMist® - Preservative Free, 10x1 single dose intranasal spray (0.2mL) MedImmune Influenza 10 2 years of age up to the 19th birthday Fluvirin® - Preservative Free, 10x1 single dose syringe (0.5mL) Novartis Influenza 10 4 years of age up to the 19th birthday Due to limited supply, must be prioritized for pregnant adolescents Manufacturer Quality Control Office Telephone Numbers: sanofi pasteur, 800-822-2463, MedImmune, 877-358-6478, Novartis, 800-244-7668, LHJ Use Only DOH Use Only
SHIP TO: DATE ORDERED: SHIPPING ADDRESS: Check If Any Shipping Changes CITY: ZIP: CONTACT: TELEPHONE: FAX: DELIVERY TIMES: Please specify all days and hours your clinic is available to receive vaccine. (e.g., 9AM-3PM) Monday Tuesday Wednesday Thursday Friday Special Shipping Instructions (e.g., Closed for lunch 12-1): Vaccine Description / Guidelines for Use MUST COMPLETE ALL FIELDS BELOW* Doses Used Last Month Doses On Hand Minimum Order (Doses) Number of Ordered Influenza Fluzone® - Preservative free, 10x1 single dose pre-filled syringe (0.25mL) sanofi-pasteur 6 months of age up to the 3rd birthday 10 Influenza Fluzone® - Multi-dose vial (5.0mL) sanofi-pasteur 3 years of age up to the 19th birthday 10 Influenza FluMist® - Preservative Free, 10x1 single dose intranasal spray (0.2mL) MedImmune 2 years of age up to the 19th birthday 10 Influenza Fluvirin® - Preservative Free, 10x1 single dose syringe (0.5mL) Novartis 4 years of age up to the 19th birthday Due to limited supply, must be prioritized for pregnant adolescents 10 PROVIDER REQUEST FOR CHILDHOOD VACCINE SEASONAL INFLUENZA VACCINE 2011-2012 Provider PIN#: used last month and doses on hand for each vaccine, including vaccines not ordered, are required with every order For more information, see Immunization Guidelines for the Use of State-Supplied Vaccines at: Manufacturer Quality Control Office Telephone Numbers: sanofi pasteur, 800-822-2463, MedImmune, 877-358-6478, Novartis, 800-244-7668, LHJ Use Only DOH Use Only
ChildhoodVaccineRequestForm_WORD.docx