ALABAMA DEPARTMENT of PUBLIC HEALTH
 
VFC Influenza Vaccine Order Form 2021-2022

2021-2022 INFLUENZA VACCINE ORDER FORM ALABAMA VACCINES FOR CHILDREN PROGRAM
Generally in January and February of each year, the Alabama Vaccines For Children (AL VFC) Program ask VFC providers to submit their preferred presentations of VFC influenza (flu) vaccine by mail/email, which is called prebook. CDC requests from all state VFC Programs their pre-booked orders by mid-February. The AL VFC Program approves orders to be distributed based on what is in stock. Influenza orders will be submitted to the National Centralized Distribution Center in the order they are received. Providers are notified if their preferred presentation is no longer available and AL VFC Program will ask providers if they will accept another presentation not requested.

* Today's Date

* VFC Site Name

* Contact Person

* VFC PIN

* Shipping Address

* City

* State

* Zip Code

* Phone #

* Email Address

* Special Delivery Instructions (e.g. days/hours closed)


Please email vfc@adph.state.al.us with any questions. Please indicate the vaccine presentation you prefer. If preferred presentation is not available, you will receive what is available. PLEASE ENTER THE NUMBER OF DOSES IN 10 DOSE INCREMENTS IN THE SPACES PROVIDED.

If the vaccine presentation that I requested is not available, I agree that another presentation can be substituted in its place.

I agree  

Fluzone Quad (Age 6 mths and older) Multi-dose vials

Fluzone Quad (6 mths and older) No Preservative - 10 single dose vials

Fluzone Quad (6 mths and older) No Preservative - 10 single dose syringes

Fluarix Quad (6 mths and older) No Preservative -10 single dose syringes

Flucelvax Quadrivalent (6 mths and older) - 10 Single dose syringes

FluLaval Quadrivalent (6 mths and older) No Preservative - 10 Single dose syringes

FluMist Quadrivalent (2 yrs and older) No Preservative - 10 Single dose sprayer

Afluria Quadrivalent (6-35 months) No Preservative - 10 single dose syringe