VS02 - Niagara Region Vaccine Order Form for Physicians and Primary Care

Niagara Region - Vaccine Order Form for Physicians and Primary Care
Order No*
Program assistant initials*
All vaccine orders require: A copy of your current 4 week fridge temperature log (up to present day) 3 full business days to fill the order
Name of Clinic *
Clinic Phone Number*
Ext
Clinic Email*
example@example.com
Contact/ Clinic Staff*
Date mmddyyyy*

MonthDayYear
Date

Vaccine Order - Vaccine on Hand (Default is Zero)
DTaP-IPV-Hib 5- doses/pkg
Pneumococcal 15-valent Conjugate - 1/10 doses/pkg
Rotavirus - 1/10 doses/pkg
Meningococcal C Conjugate- 10 doses/pkg
MMR- 10 doses/pkg
Varicella (Chickenpox) - 10 doses/pkg
Tdap-IPV (Tetanus, diphtheria, acellular pertussis, Polio) - 10 doses/pkg
MMRV- 10 doses/pkg
IPV (Inactivated Polio) - 1 doses/pkg
Tdap - 5/10 doses/pkg
Td (Tetanus, diphtheria) - 10 doses/pkg
Pneumococcal 20-valent Conjugate - 10 doses/pkg
Tuberculin - 10 doses/pkg
Zoster (Shingles) - 1/10 doses/pkg
Vaccine for pregnant individuals(RSVpre-F) - 1/10 doses/pkg
Monoclonal antibody (mAb) for infants and high-risk children (Beyfortus 50 mg) - 1/5 doses/pkg
Monoclonal antibody (mAb) for infants and high-risk children (Beyfortus 100 mg) - 1/5 doses/pkg

Vaccine Order
DTaP-IPV-Hib 5 - doses/pkg
Pneumococcal 15-valent Conjugate - 1/10 doses/pkg
Rotavirus - 1/10 doses/pkg
Meningococcal C Conjugate- 10 doses/pkg
MMR- 10 doses/pkg
Varicella (Chickenpox) - 10 doses/pkg
Tdap-IPV (Tetanus, diphtheria, acellular pertussis, Polio) - 10 doses/pkg
MMRV- 10 doses/pkg
IPV (Inactivated Polio) - 1 doses/pkg
Tdap - 5/10 doses/pkg
Td (Tetanus, diphtheria) - 10 doses/pkg
Pneumococcal 20-valent Conjugate - 10 doses/pkg
Tuberculin - 10 doses/pkg
Zoster (Shingles) - 1/10 doses/pkg
Vaccine for pregnant individuals(RSVpre-F) - 1/10 doses/pkg
Monoclonal antibody (mAb) for infants and high-risk children (Beyfortus 50 mg) - 1/5 doses/pkg
Monoclonal antibody (mAb) for infants and high-risk children (Beyfortus 100 mg) - 1/5 doses/pkg

Niagara Region - Vaccine Order Form for Physicians and Primary Care