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]
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