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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

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

Yes No


* Delivery or Pick-up Preference

Please choose a pick-up location:

Type of Refrigerator

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

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

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

For more information about vaccines, visit Ontario's Publicly Funded Immunization Schedules
must be ordered
in increments of:
Current Stock
(# of doses)
# of Doses
Hib: 1 dose
Adacel® / Boostrix® (Tdap): 5 doses
Adacel® Polio / Boostrix® Polio (TdapIPV): 10 doses
IMOVAX® - Inactivated Polio (IPV): 1 dose
Menjugate® / NeisVac-C® (Men-C)
≥12 months (and up to 11 years of age
for school attendance):
10 doses
MMR® II / Priorix® & diluent (MMR)
≥12 months (for school attendance):
10 doses
Pediacel® (DTaP-IPV Hib): 5 doses
Pneumovax® 23 (Pneu PS): 10 doses
Pneumococcal Immunization Decision Tool – High Risk Patient
Prevnar® 13 (Pneumococcal Conjugate)
< 2 years and /or
High Risk Adults > 50 years:
10 doses
Pneumococcal Immunization Decision Tool – High Risk Patient
Priorix Tetra ™ / ProQuad ® & diluent (MMRV): 10 doses
RotaTeq® (Rotarvirus): 10 doses
Td Adsorbed (for 7 years and over): 5 doses
Tubersol® - TB Mantoux: 10 doses
Varivax® III / Varilrix® & diluent(Varicella): 10 doses
Do you have a booked appointment for a client who is 70 years of age?
Yes    No
The maximum quantity is 2 doses. Administer to patients who are 70 years of age only. More information is available here.
Zostavax® (HZV) 1 dose
Vaccine Related Supplies


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 ZZG-VMPIOrderRequests@peelregion.ca.

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Revised: June 13, 2019


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