Toronto Public Health Vaccine Order Form
OGPMSS Number
*
Date of Requisition yyyymmdd
*
/
Year
/
Month
Day
Date
Name of Clinic
*
Name
*
First Name
Last Name
Clinic Phone Number
*
Clinic Fax Number
*
Clinic Email Address
*
example@example.com
Number of dedicated vaccine refrigerators
Type a question
Fridge ID (e.g. BAR001, PUR001 ...)
*
Shipping Address
Unit Number
Street Number
*
Street Name
*
PO Box
City/Town
*
Postal Code
*
Clinic Staff Making Request
*
Signature of Clinic Staff Making Request
*
Vaccine Order - Vaccine on Hand (Deult is Zerofa)
Tubersol (TB) - 10 dose/pkg
DTap-IPV-Hib (Pertussis, Diphtheria, Tetanus, Polio) - 5 dose/pkg
Hib (Haemophilus influenzae) - 5 dose/pkg
IPV (polio vaccine) - 1 dose/pkg
Men-C-C (meningcococcal C) - 10 dose/pkg
MMR (measles, mumps, and rubella) - 10 dose/pkg
MMRV (measles, mumps, rubella, and varicella) - 10 dose/pkg
Pneu-C-15 (pneumococcal conjugate vaccine, 15-valent)- 1 dose/pkg
Pneu-C-15 (pneumococcal conjugate vaccine, 15-valent)- 10 dose/pkg
Pneu-C-20 (pneumococcal conjugate vaccine, 20-valent)- 10 dose/pkg
Rot-1 (rotavirus vaccine) - 10 dose/pkg
Td (tetanus and diphteria vaccine) - 10 dose/pkg
Tdap (tetanus, diphteria and pertussis vaccine) - 5 dose/pkg
Tdap-IPV (tetanus, diphtheria, pertussis and polio vaccine) - 10 dose/pkg
Var (varicella vaccine) - 10 dose/pkg
Zos (herpes zoter) - 1 dose/pkg
Vaccine Order
Tubersol (TB) - 10 dose/pkg
DTap-IPV-Hib (Pertussis, Diphtheria, Tetanus, Polio) - 5 dose/pkg
Hib (Haemophilus influenzae) - 5 dose/pkg
IPV (polio vaccine) - 1 dose/pkg
Men-C-C (meningcococcal C) - 10 dose/pkg
MMR (measles, mumps, and rubella) - 10 dose/pkg
MMRV (measles, mumps, rubella, and varicella) - 10 dose/pkg
Pneu-C-15 (pneumococcal conjugate vaccine, 15-valent)- 1 dose/pkg
Pneu-C-15 (pneumococcal conjugate vaccine, 15-valent)- 10 dose/pkg
Pneu-C-20 (pneumococcal conjugate vaccine, 20-valent)- 10 dose/pkg
Rot-1 (rotavirus vaccine) - 10 dose/pkg
Td (tetanus and diphteria vaccine) - 10 dose/pkg
Tdap (tetanus, diphteria and pertussis vaccine) - 5 dose/pkg
Tdap-IPV (tetanus, diphtheria, pertussis and polio vaccine) - 10 dose/pkg
Var (varicella vaccine) - 10 dose/pkg
Zos (herpes zoter) - 1 dose/pkg
Misc Supplies
Vaccine Temp Log Book
Email
example@example.com
Immunization Cards (Yellow)
Ice Packs
Checkbox
Type option 1
Preview PDF
Submit
Should be Empty: