Vaccine Order Form

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Refer to the Publicly Funded Immunization Schedules for Ontario for eligibility criteria
I have attached a copy of our fridge temperatures since our last order to verify that vaccine has been stored between +2˚ C and +8˚ C and min/max temperatures have been recorded twice daily.
All orders must be faxed to the Health Unit at 519-426-9246 by 12:00 p.m. on Thursday. Your order will be available for pick up on the following Thursday after 2:00 p.m. Please note, pick up time at the Health Unit are Monday-Friday between 8:45 a.m. and 4:15 p.m.•
Pick up Location*
YYYY slash MM slash DD

Hepatitis A (Avaxim®/Havrix®)

YYYY slash MM slash DD
HIGH RISK ELIGIBILITY > – ≥ 1 year with:*
(please check all that apply)
Product Alternate ID 657132570

Haemophilus influenzae type b (Act-HIB®)

YYYY slash MM slash DD
HIGH RISK ELIGIBILITY > – ≥ 1 year with:*
(please check all that apply)
Product Alternate ID 657132430
By Submitting this order, 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.
  • Accurate temperature logs will be provided upon request and are kept on site until our next annual cold chain inspection.
  • 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.

Note: If you are unable to verify any of the above, call the Haldimand Norfolk Health Unit at 519-426-6170 Ext. 3214.