Seasonal Vaccines – COVID-19, Influenza, RSV Order Form - Leeds, Grenville and Lanark District Health Unit

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)

Type of Seasonal Vaccine(s) you would like to order(Required)

COVID-19 Vaccines

Influenza Vaccines

RSV Vaccines

Please check all that apply.

COVID-19 Vaccines

Which COVID-19 Vaccine(s) would you like to order?(Required)

Pfizer KP 2 (12 years and older) 6 doses per vial

Moderna KP 2 (6 months and older) 5 adult doses per vial

Pfizer KP 2 (12 years and older) Doses Currently in our Vaccine Fridge(Required)

6 dose vials

Pfizer KP 2 (12 years and older) Doses Required(Required)

6 dose vials

Moderna KP 2 (6 months and older) Doses Currently in our Vaccine Fridge(Required)

5 adult doses per vial

Moderna KP 2 (6 months and older) Doses Required(Required)

5 adult doses per vial

Influenza Vaccines

Order may be completed with prefilled syringes or multi-dose vials, depending on vaccine availability.

Influenza Vaccines(Required)

QIV – 6 months and older – may be Flu Laval or Fluzone vaccine

QIV HD – 65 and older – may be Fluzone or Fluad vaccine

TIV - 65 and older – Fluad vaccine

QIV Doses Currently in our Vaccine Fridge(Required)

6 months and older – may be Flu Laval or Fluzone vaccine.

QIV Doses Required(Required)

6 months and older – may be Flu Laval or Fluzone vaccine.

QIV HD Doses Currently in our Vaccine Fridge(Required)

65 and older – may be Fluzone or Fluad vaccine.

QIV HD Doses Required(Required)

65 and older – may be Fluzone or Fluad vaccine.

TIV Doses Currently in our Vaccine Fridge(Required)

65 and older – Fluad vaccine.

TIV Doses Required(Required)

65 and older – Fluad vaccine.

RSV Vaccines

Children - See High Risk Section to Order

Seniors (must be aged 60+ to receive publically funded vaccine and in one of these groups) - please indicate which group(Required)

Long-Term Care

Retirement Home

Hospital ALC Patients

Dialysis Patients (Hemo or Peritoneal)

Recipients of solid organ or HSC transplant

Individuals experiencing homelessness

Individuals who identify as First Nations, Inuit or Metis

RSV Vaccine Doses Currently in our Vaccine Fridge(Required)

1 dose per box/vial
Must be reconstituted 0.5 ml dose I.M.

RSV Vaccine Doses Required(Required)

1 dose per box/vial
Must be reconstituted 0.5 ml dose I.M.

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

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Seasonal Vaccines – COVID-19, Influenza, RSV Order Form

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.

Influenza Vaccine Returns

COVID-19 Vaccine – Spring 2025 Campaign

Vaccine Contact

COVID-19 Vaccines

Influenza Vaccines

RSV Vaccines

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.***

Influenza Vaccine Returns

COVID-19 Vaccine – Spring 2025 Campaign

Vaccine Contact

COVID-19 Vaccines

Influenza Vaccines

RSV Vaccines

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.