Routine Vaccines and Vaccine Storage and Handling Resources Order Form

Holding Point Number - see yellow sticker on vaccine fridge(Required)

LGL_BR_00###

Health Care Provider Location *Please insert your official facility name used by MOHLTC(Required)

Requisition Date(Required)

Type of Request(Required)

Routine order as per order cycle

Urgent - must pick up in Brockville or Smiths Falls

Type of Urgent Request(Required)

Replacement Vaccine due to ASC

Unexpected shortage and booked appointments

Other

Health Unit Office Pick Up Location(Required)

Vaccine Contact

Vaccine Contact Name(Required)

First Name Last Name

Phone(Required)

Extension

Email(Required)

Please indicate which you will be ordering: Routine Vaccines and/or Vaccine Storage and Handling Resources

What will you be ordering?(Required)

Routine Vaccines

Vaccine Storage and Handling Resources

Which Routine Vaccine(s) would you like to order?(Required)

Which Vaccine Storage and Handling Resources would you like to order?(Required)

Do Not Unplug sticker - English

How to Monitor Refrigerator Temperature sticker - English

Immunization Cards

Protect Your Vaccines - Protect Your Patients poster - English

Stop sticker - English

Vaccine Refrigerator Maintenance Log Book - English

Vaccine Temperature Log Book - English

Routine Vaccines

Rotavirus Vaccine Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-4233-0 1 dose per package

Rotavirus Vaccine Doses Required(Required)

Catalogue number 6571-4233-0 1 dose per package

Prevnar 15 Vaccine (Pneu-C-15) Doses Currently in our Vaccine Fridge(Required)

Prevnar 15 Vaccine (Pneu-C-15) Doses Required(Required)

DTap-IPV-Hib Vaccine (Pediacel) Doses Currently in the Fridge(Required)

DTap-IPV-Hib Vaccine (Pediacel) Doses Required(Required)

Men C-C (Menjugate/NeisVac) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-3344-3
10 doses per package

Men C-C (Menjugate/NeisVac) Doses Required(Required)

Catalogue number 6571-3344-3
10 doses per package

MMR Vaccine (MMRII/Priorix) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-3230-0
10 doses per package

MMR Vaccine (MMRII/Priorix) Doses Required(Required)

Catalogue number 6571-3230-0
10 doses per package

MMR-V Vaccine (Pro-Quad/Prioix-Tetra) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-3604-0
10 doses per package

MMR-V Vaccine (Pro-Quad/Prioix-Tetra) Doses Required(Required)

Catalogue number 6571-3604-0
10 doses per package

Varicella Vaccine (Varilrix/Varivax) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-3305-0
10 doses per package

Varicella Vaccine (Varilrix/Varivax) Doses Required(Required)

Catalogue number 6571-3305-0
10 doses per package

Tdap Vaccine (Adacel/Boostrix) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-2203-0
5 doses per package

Tdap Vaccine (Adacel/Boostrix) Doses Required(Required)

Catalogue number 6571-2203-0
5 doses per package

Tdap-IPV Vaccine (Adacel-IPV/Boostrix-Polio) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-2013-1
10 doses per package

Tdap-IPV Vaccine (Adacel-IPV/Boostrix-Polio) Doses Required(Required)

Catalogue number 6571-2013-1
10 doses per package

Td Adsorbed Vaccine Doses Currently in our Vaccine Fridge(Required)

Td Adsorbed Vaccine Doses Required(Required)

Prevnar20 Vaccine (Pneu-C-20) Doses Currently in our Vaccine Fridge(Required)

Prevnar20 Vaccine (Pneu-C-20) Doses Required(Required)

Shingles (Shingrix Vaccine) Doses Currently in our Vaccine Fridge(Required)

Catalogue number 6571-2020-1
1 or 10 doses per package

Shingles (Shingrix Vaccine) Doses Required(Required)

Catalogue number 6571-2020-1
1 or 10 doses per package

Polio (IPV Imovax) Vaccine Doses Currently in our Vaccine Fridge(Required)

Polio (IPV Imovax) Vaccine Doses Required(Required)

Vaccine Storage and Handling Resources

Do Not Unplug sticker – English – Quantity Required(Required)

Catalogue number 7540-1954-0

How to Monitor Refrigerator Temperature sticker – English – Quantity Required(Required)

Catalogue number 7540-1938-0

Immunization Cards (package of 25) – Quantity Required(Required)

Package of 25

Protect Your Vaccines – Protect Your Patients poster – English - Quantity Required(Required)

Catalogue number 7540-1922-0

Stop sticker – English – Quantity Required(Required)

Catalogue number 7540-1955-0

Vaccine Refrigerator Maintenance Log Book – English – Quantity Required(Required)

Vaccine Temperature Log Book – English – Quantity Required(Required)

Catalogue number 7610-1908-0

By submitting this order and signing below, I verify on behalf of the practice the following:

- Refrigerators have maintained temperatures between +2°C to +8°C and temperatures are documented twice daily

- I will submit vaccine fridge temperature logs for the past month after submitting this order to [email protected]

- All temperature excursions outside of +2°C to +8°C (if applicable) have been reported to and recommendations regarding usage of the effected vaccines have been implemented by the practice

- A contingency plan is in place should a power outage and/or cold chain incident occur, including vaccine coolers and extra temperature monitoring devices

- That publically funded vaccines and other products ordered from the Health Unit will only be administered to eligible recipients as per the Publically Funded Immunization Schedule for Ontario and other related provincial guidance documents

Ready to submit(Required)

Yes

Comments

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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.

Vaccine Contact

Please indicate which you will be ordering: Routine Vaccines and/or Vaccine Storage and Handling Resources

Routine Vaccines

Vaccine Storage and Handling Resources

By submitting this order and signing below, I verify on behalf of the practice the following:

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.***

Vaccine Contact

Please indicate which you will be ordering: Routine Vaccines and/or Vaccine Storage and Handling Resources

Routine Vaccines

Vaccine Storage and Handling Resources

By submitting this order and signing below, I verify on behalf of the practice the following:

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