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public health > health professionals > influenza vaccine order request 2018/2019

Influenza Vaccine Order Request 2018/2019

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.

Before filling out this request, please confirm:




Order Information
(*) Mandatory fields
RMP_MS_



















Yes No

Ext.



Delivery or Pick-up Preference (Select One)

Free vaccine delivery for Influenza Vaccine Orders only between October to December. After December influenza orders can be picked up at your regular pick up location or via the paid delivery program.


Orders must be picked up within 3 business days of phone call from Peel Public Health.




Type of Refrigerator

Please indicate the number of refrigerators approved for storage of influenza vaccine:



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

Note: Provide current stock of ALL flu vaccine products in fridge.

Note: Due to high volumes of influenza vaccine orders being processed, you may experience delays in receiving your vaccine orders.

Note: Your vaccine order may be reduced based on current available stock and your facility's previous season's influenza vaccine use and wastage.

Influenza Vaccine Brand Vaccine Formulation Vaccine Eligibility by Age Group Packaging
Fluzone® Quadrivalent
Flulaval® Tetra
QIV 6 months and older Multi-Dose Vial
*Fluzone® Quadrivalent Current Stock
*Flulaval® Tetra Current Stock
# of doses Required Vaccine must be ordered in increments of:10
 
Fluzone ® Quadrivalent QIV 6 months and older Single Dose Pre-filled Syringes
* Current Stock
# of doses Required Vaccine must be ordered in increments of:10
Unavailable for now
 
Flumist® Q-LAIV 2 years to less than 18 years of age Pre-Filled Single Use Intranasal Sprayers
* Current Stock
# of doses Required Vaccine must be ordered in increments of:10
 
Fluzone ® High-Dose TIV 65 years and older Single Dose Pre-filled Syringes
* Current Stock
# of doses Required Vaccine must be ordered in increments of:5
 
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 temperature logs from your last order until today are faxed to 905-565-9874 or emailed to us at
ZZG-VMPIOrderRequests@peelregion.ca.


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Revised:November 15, 2018

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