High Risk Vaccines Internal Form Search Submit Search Print this Page Home » For Professionals » Vaccine Ordering & Guidance » Orders and Returns – Vaccines » High Risk Vaccines Internal Form This form is intended for Health Unit staff. Holding Point Number - see yellow sticker on vaccine fridge(Required)LGL_BR_00011 - AlmonteLGL_BR_00004 - BrockvilleLGL_BR_00009 - KemptvilleLGL_BR_00012 - GananoqueLGL_BR_00007 - Smiths FallsLGL_BR_00131 - Schools - NorthLGL_BR_00005 - Schools - SouthRequisition Date(Required) Month Day Year Health Unit Office Pick Up Location(Required) Brockville Gananoque Kemptville Smiths Falls Almonte Vaccine ContactVaccine Contact Name(Required) First Name Last Name Phone(Required)ExtensionEmail(Required) Which High Risk Vaccine(s) would you like to order? *Review eligibility for publically funded vaccine before placing an order (no separate form)(Required) RSV vaccine in pregnancy (currently unavailable) Hepatitis A Vaccine, Pediatric Hepatitis A Vaccine, Adult Hepatitis B (Pediatric) Vaccine Hepatitis B (Adult) Vaccine Hepatitis B Vaccine (Recombinant) Dialysis clients only Meningococcal B Vaccine (Bexsero) Meningococcal C-ACYW135 Vaccine (Menactra) (NOT SCHOOL) Meningococcal P-ACYW1135 Vaccine (Menomune) Act-HIB - Eligibility – ≥ 5 years with: (please check all that apply) Rabies Vaccine - Hospitals and Community Paramedics ONLY Rabies Immune Globulin (RIG) – Hospitals ONLY Tubersol - eligible recipients are those who are listed in the OHIP Bulletin for funded TST. mPOX Vaccine HPV Vaccine (MSM) These vaccines are provided in very limited quantities - please do not maintain a stock in your fridge, and only order when you have a specific client in need.Act-HIB - Eligibility – ≥ 5 years with: (please check all that apply)(Required) Hematopoietic stem cell transplant (HSCT) recipient* (3 doses) Functional or anatomic asplenia (1 dose) Immunocompromised related to disease or therapy (1 dose) Lung transplant recipient (1 dose) Cochlear implant recipient (pre/post implant) (1 dose) Primary antibody deficiency (1 dose) Bone marrow or solid organ transplant recipient (1 dose) RSV vaccine in pregnancy (Abrysvo – Arexvy is not to be used) Doses Currently in our Vaccine Fridge(Required)RSV Guidance – Infant ProgramRSV vaccine in pregnancy (Abrysvo – Arexvy is not to be used) Doses Required(Required)RSV Guidance – Infant ProgramAct-HIB Doses Currently in our Vaccine Fridge(Required)Act-HIB Doses Required(Required)Hepatitis A Vaccine, Pediatric Doses Currently in our Vaccine Fridge(Required)Hepatitis A Vaccine, Pediatric Doses Required(Required)Hepatitis A Vaccine, Adult Doses Currently in our Vaccine Fridge(Required)Hepatitis A Vaccine, Adult Doses Required(Required)Hepatitis B (Pediatric) Vaccine Doses Currently in our Vaccine Fridge(Required)Hepatitis B (Pediatric) Vaccine Doses Required(Required)Hepatitis B (Adult) Vaccine Doses Currently in our Vaccine Fridge(Required)Hepatitis B (Adult) Vaccine Doses Required(Required)Hepatitis B Vaccine (Recombinant) Doses Currently in our Vaccine Fridge(Required)Dialysis clients onlyHepatitis B Vaccine (Recombinant) Doses Required(Required)Dialysis clients onlyMeningococcal B Vaccine (Bexsero) Doses Currently in our Vaccine Fridge(Required)Meningococcal B Vaccine (Bexsero) Doses Required(Required)Meningococcal C-ACYW135 Vaccine (Menactra) Doses Currently in our Vaccine Fridge(Required)(NOT SCHOOL)Meningococcal C-ACYW135 Vaccine (Menactra) Doses Required(Required)(NOT SCHOOL)Meningococcal P-ACYW1135 Vaccine (Menomune) Doses Currently in our Vaccine Fridge(Required)Meningococcal P-ACYW1135 Vaccine (Menomune) Doses Required(Required)Rabies Vaccine Doses Currently in our Vaccine Fridge(Required)Hospitals and Community Paramedics ONLYRabies Vaccine Doses Required(Required)Hospitals and Community Paramedics ONLYRabies Immune Globulin (RIG) Doses Currently in our Vaccine Fridge(Required)Hospitals ONLYRabies Immune Globulin (RIG) Doses Required(Required)Hospitals ONLYTubersol Doses Currently in our Vaccine Fridge(Required)Eligible recipients are those who are listed in the OHIP Bulletin for funded TST.Tubersol Doses Required(Required)Eligible recipients are those who are listed in the OHIP Bulletin for funded TST.mPOX Doses Currently in our Vaccine Fridge(Required)mPOX Doses Required(Required)HPV Vaccine (MSM) Doses Currently in our Vaccine Fridge(Required)HPV Vaccine (MSM) Doses Required(Required)Ready to submit(Required) Yes Comments - Please indicate the high risk criteria met in order to give this funded vaccine.(Required)CAPTCHA