Vaccine Info request form

Vaccine Inventory Request Form
This form is used to add vaccine information to the Practices Vaccine Inventory list.
Contact Information
Date

MonthDayYear
Date
Practice*
Requestor*

First NameLast Name
Phone Number*

Area CodePhone Number
Extension
Vaccine Information
⚠️Please refer to the CDC website for verification of NDC, CVX, and CPT codes.
https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cvx
Trade Name (Vaccine Name) *
Manufacturer*
Vial or Syringe
Indicate if a multidose vial or prefilled syringes.
# of vials or syringes received? *
CPT Code*
CVX Code
NDC # with dashes*
Lot #*
Expiration Date *
Comments
Questions? Please direct all inquiries to NGsupport@mydohc.com
Should be Empty:

Vaccine Inventory Request Form