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public health > health professionals > vaccine order request 2016

Vaccine Order Request

You must provide an email address for online orders so that we can send you a confirmation email for receipt of your order.

For questions about completing this form, please contact the Vaccine Order Desk at
905-791-7800 ext. 6404.

I have confirmed:




Order Information
(*) Mandatory fields
RMP_MS_

Date of Pick-up: Two Business days after order is received.
(For exceptions, see Delivery or Pick-up Preference section)

















Yes No

Ext.



* Delivery or Pick-up Preference

Please choose a pick-up location:






* Please order no more than a ONE month supply of vaccines

Note: If you are not ordering the vaccine, Current Stock is not required.

Vaccines
For more information about vaccines, visit Ontario's Publicly Funded Immunization Schedules
Vaccine
must be ordered
in increments of:
Current Stock
(# of doses)
# of Doses
Required
Act-HIB® (HIB): 5 doses
Adacel® / Boostrix® (Tdap): 5 doses
Adacel® Polio / Boostrix® Polio (TdapIPV): 10 doses
IMOVAX® - Inactiviated Polio (IPV): 1 dose
Menactra® (Men-C-ACYW):
For clients who are in grades 9-12 (secondary or home school setting) and
received a notice from Peel Public Health indicating they are overdue for
Meningococcal vaccine.
Maximum 10 doses.
1 dose
Menjugate® / NeisVac-C® (Men-C): 10 doses
MMR® II / Priorix® & diluent (MMR): 10 doses
Pediacel® (DTaP-IPV Hib): 5 doses
Pneumovax® 23 (Pneu PS): 10 doses
Prevnar® 13 (Pneumococcal Conjugate)
< 2 years and /or
High Risk Adults > 50 years:
10 doses
Priorix Tetra ™ / ProQuad ® & diluent (MMRV): 10 doses
Infanrix® - IPV (DTaP-IPV):
Special request for use in clients 5-6 years of age ONLY. Used for primary immunization or unknown immunization history.
Maximum 4 doses.
2 doses
Rotarix™ (Rotavirus): 1 dose
Td Adsorbed (for 7 years and over): 5 doses
Tubersol® - TB Mantoux: 10 doses
Varivax® III / Varilrix® & diluent(Varicella): 10 doses
Zostavax® (HZV):
For clients between 65 and 70 years of age. On a one-time basis, until December 31, 2016, clients born in 1945 are eligible to receive the shingles vaccine.
1 dose
Vaccine Related Supplies


Quantity:
Quantity:
Quantity:

If you have been notified by Peel Public Health to submit temperature logs with your vaccine orders, please ensure that logs spanning from your last order until today are emailed to us at VMPIOrderRequest@peelregion.ca.


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Revised: December 05, 2016

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