Required fields are marked with asterisks (*)

School-Based Immunization Program vaccine orders

School-based immunization program vaccines are only released under extenuating circumstances.

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 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.

Name of facility, physician, or practice

Main fridge code

Phone number (999-999-9999)

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

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

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

Extension

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

Yes

For school vaccines, an immunization nurse will assess for eligibility before providing the vaccine(s). We require any previous doses to be reported so we can enter them into the client database, and will not release the next dose until we receive this information.

Please complete the High Risk and School Publicly Funded Immunization Program Reporting Form and fax to 613-549-0985.

Client information

First and last name

Date of birth (year, month, day)

OHIP number

Name of physician

School

Unable to attend school-based clinic(s) due to (please check all that apply)

School board decision

Alternative school arrangement

Medical considerations

History of previous vaccine reaction

History of allergic reaction

Medical contraindication for school-based clinic

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

Hepatitis B

Meningococcal C-ACYW135

Human Papillomavirus - HPV 9 vaccine

Order vaccines for another client 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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