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High Risk Vaccines Order Form

Review these eligibility criteria PRIOR to placing an order for a high risk publically funded vaccine. If the client does not meet the criteria, they must access vaccine via a prescription from the pharmacy. See the Publically Funded Schedule for dosing information. If unsure, please contact [email protected]

RSV Guidance – Infant Program

Tuberculosis (TB) Skin Test OHIP Bulletin

Hepatitis A Eligibility – ≥ 1 year including those with one of the following

  • Persons with chronic liver disease including hepatitis B and C
  • Persons engaging in intravenous drug use
  • Men who have sex with men

Hepatitis B Eligibility ≥ 0 years including one of the following:

  • Infants born to HBV-positive carrier mothers:
    • Premature infants weighing <2,000 grams at birth (4 doses)
    • Premature infants weighing ≥2,000 grams at birth and full/post term infants (3 doses)
  • Household and sexual contacts of chronic carriers and acute cases (3 doses)
  • Individuals engaging in intravenous drug use (3 doses)
  • Men who have sex with men, individuals with multiple sex partners, and history of a sexually transmitted disease (3 doses)
  • Individuals having needle stick injuries in a non-health care setting (3 doses)
  • Children <7 years old whose families have immigrated from countries of high prevalence for hepatitis B and who may be exposed to hepatitis B carriers through their extended families (3 doses)
  • Individuals with chronic liver disease including hepatitis C (3 doses)
  • Individuals on renal dialysis and those with diseases requiring frequent receipt of blood products (e.g., haemophilia) (Second and Third doses only)
  • Individuals awaiting liver transplants (Second and Third doses only)

Meningococcal B ages 2 months to 17 years

  • Individuals with functional or anatomic asplenia
  • Individuals with complement, properdin, factor D or primary antibody deficiencies
  • Cochlear implant recipients (pre/post implant)
  • Individuals with acquired complement deficiencies (e.g., receiving eculizumab)
  • Individuals with HIV

Meningococcal C-ACYW135 ages 9 months and over – see schedule for dosing information

  • Individuals with functional or anatomic asplenia
  • Individuals with complement, properdin, factor D or primary antibody deficiencies
  • Cochlear implant recipients (pre/post implant)
  • Individuals with acquired complement deficiencies (e.g., receiving eculizumab)
  • Individuals with HIV

Complete ALL fields to avoid a delay in processing your vaccine order. You will receive an email with a copy of your order when you successfully submit your order.

***Vaccine Fridge Temperature logs for the previous 4 weeks must be submitted by email to [email protected] when you place an order.***

Review eligibility for publically funded vaccine before placing an order. (no separate form)

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.

Note: If You are unable to verify all of the Cold Chain Requirements above, email [email protected] or call 1-800-660-5853