Order Form

Order ALL needed vaccines at one time for a 3-Month period and reorder when your clinic is down to a 2-week supply. This procedure ensures that your clinic does not run out of vaccine and that vaccine is used before it expires. If pre-filled syringes or requested vaccine brands are not available, you will receive what is currently available.

If you have any questions, call 1-800-469-4599.

Name of Clinic/Practice:     VFC PIN:
Shipping Address:

(Sorry, we cannot ship to a P.O. Box)
City:     Zip Code:
Contact Person:
Phone #:             FAX #:
Back-up System to Receive Vaccine? Yes or No
Special Delivery Instructions (i.e. days/hrs closed):
Email address for confirmation: (This field is required)

Vaccine Types	Specific Information	Current VFC Inventory in Doses	Doses Used	Order (In Doses Only)
DT	6 weeks - 6 years of age - medical contraindication to pertussis vaccine
DTaP	6 weeks - 6 years of age Infanrix Pre-Filled Syringes Infanrix vials Tripedia DAPTACEL
DTaP/HepB/IPV	6 weeks - 6 years of age Pediarix Pre-Filled Syringes Pediarix vials
DTaP/IPV	4 years - 6 years only Kinrix Kinrix Pre-Filled Syringes Kinrix vials
DTaP/IPV/Hib	6 weeks - 4 years of age Pentacel
EIPV	6 weeks - 18 years of age IPOL IPOL Pre-Filled Syringes IPOL vials
Hep A	(2 dose) 1 year - 18 years of age Havrix Pre-Filled Syringes Havrix vials Vaqta
Hep A & B	(3 dose) 18 years of age ONLY Twinrix Pre-Filled Syringes Twinrix vials
Hep B-PF	Birth - 18 years of age Engerix Pre-Filled Syringes Engerix Vials Recombivax
Hep B/Hib	6 weeks - 5 years of age Comvax
Hib	6 weeks - 5 years of age ActHib Pedvax
HPV	Gardasil
Meningococcal Conjugate (MCV4)	11 yrs - 15 yrs of age Menactra
MMR with Diluent	1 year - 18 years of age MMR II
MMRV	1 year - 12 years of age ProQuad
Pneu 7 (PCV) Conjugate	6 weeks - 59 months of age Prevnar Pre-Filled Syringes Only
Pneu 23 (PPV) Polysaccharide	2 years - 18 years of age High Risk Only Pneumovax 23
Rotavirus (RV1)	Rotarix ORAL ADMINISTRATION ONLY
Rotavirus (RV5)	RotaTeq ORAL ADMINISTRATION ONLY
Td	7 years - 18 years of age Decavac Pre-Filled Syringes Decavac Vials
Tdap	10 years - 18 years of age Boostrix Pre-Filled Syringes Boostrix Vials
Tdap	11 years - 18 years of age Adacel Pre-Filled Syringes Adacel Vials
Varicella**	Use for 12-15 months and 4 thru 6 yrs only Varivax

Where you have a choice of vaccines, please select one. If no selection is made, or if we cannot determine which vaccine you prefer, at our discretion we will make the selection.

ADPH-IMM-502 11/06