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Influenza Vaccine Order Form

Initial and priority-based influenza vaccine orders have been completed. You many submit additional orders based on your current supply and clinic needs. We will continue to process influenza vaccine orders based on supply and we will work with vaccine providers to increase allocations as needed.

Order and pick-up instructions

Napanee based orders

Napanee orders need to be submitted by noon on Wednesday to be ready for pick-up at the Napanee office the following week.
Napanee office pick-up available Monday 1:00 to 4:30 pm and Tuesday to Friday 8:30 am to 12:00 pm and 1:00pm to 4:30pm.

Kingston based orders

Orders will be ready 72 hours after the order is placed. Kingston office pick up available Monday to Friday 8:30am to 4:30pm.

You may place your order now. All orders will be processeed as soon as product is available.

Please note that in some instances it may take longer than 72 hours to be processed, due to the approval process.

Temperature logs

Attach temperature log with temperatures from previous four weeks or since last order date

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

If needed, download the Vaccine Temperature Log to document your dates and temperatures.

Facility information

Name of facility

Main fridge code

Phone number (999-999-9999)

Extension

Email address (we will send you a copy of this order for your records)

Approximate number of patients in practice

Approximate number of staff

Approximate number of residents OVER 65 years of age

Approximate number of residents UNDER 65 years of age

Approximate number of CAREGIVERS expected to receive the influenza vaccine who are OVER 65 years of age

Approximate number of CAREGIVERS expected to receive the influenza vaccine who are UNDER 65 years of age

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Do you currently have any additional orders placed for vaccines or medications

Yes

Vaccine ordering

Fluzone® Quadrivalent and Fluzone® High-Dose Quadrivalent are different products. Fluzone® High-Dose Quadrivalent is only authorized for those 65 years of age and older. Please use caution when administering Fluzone® products to ensure that the right vaccine is being administered to the right person.

Type of vaccine(s) you would like to order

Please check all that apply

Quadrivalent Inactivated Vaccine (QIV)

Eligibility: 6 months and older

I would like to order Quadrivalent Inactivated Vaccine (QIV)

Yes

High-Dose Quadrivalent Inactivated Vaccine (QIV-HD)

Eligibility: 65 years and older

I would like to order High-Dose Quadrivalent Inactivated Vaccine (QIV-HD)

Yes

Adjuvanted Trivalent Vaccine (TIV-adj)

Eligibility: 65 years and older

I would like to order Adjuvanted Trivalent Vaccine (TIV-adj)

Yes

Please provide dates of influenza clinics planned at your facility if applicable, and the approximate number of required doses

Date of clinic

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comments or further details

Delivery

As per the Vaccine Storage and Handling guidelines vaccine transport is only permitted in a hard-shell cooler, cooled to between 2 to 8 degrees and monitored with a digital maximum and minimum thermometer capable of measuring in 0.1 degree increments.

Requested delivery method (please select one)

Pickup (please bring hard-shell cooler with the capacity to hold your entire order, cooled to 2 to 8°C)

Delivered by courier, arranged by KFL&A Public Health

By checking this box, I acknowledge I have read, understand, and agree that the information provided in this form is correct.

Yes