Publicly funded high risk vaccine orders

Required fields are marked with asterisks (*)

Publicly funded high risk vaccine orders

Refer to the Publicly Funded Immunization Schedule for detailed high risk eligibility criteria and vaccine intervals.

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.

Facility information

Attach temperature log with temperatures from previous 4 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.

Name of facility, physician, or practice

Phone number (999-999-9999)

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

Main fridge code

Number of fridges used to store vaccines

As per the Vaccine Storage and Handling Guidelines

Maintain no more than one month supply at a time. However depending on the size of fridge, inventory may need to be reduced to a 1 to 2 week supply to prevent overcrowding.

Staff name submitting order

Direct contact number (please provide most direct or private number)

Extension

For first doses: primary care providers should verify the eligibility of their patients for high-risk vaccines.

For subsequent doses: an immunization record will be required for entry into the provincial database before the next dose(s) can be released. Please complete the High Risk and School Publicly Funded Immunization Program Reporting Form and fax to 613-549-0985.

Should you have any questions or encounter any issues, please contact an immunization nurse at 1-613-549-1232, ext. 1451.

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

Yes

Patient information

First and last name

Date of birth (year, month, day)

OHIP number

Name of physician

I would like to order the following vaccine(s) for this client

Haemophilus influenzae type b

Meningococcal B

Meningococcal C-ACYW135

Pneu-C-20 - Pneumococcal 20-valent conjugate,

Hepatitis A

Hepatitis B

HPV 9 vaccine

comments or further details

Order vaccines for another patient Remove

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, 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

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