2016-17 MnVFC Pediatric Influenza Vaccine Late Order Form
You can submit this form via email to [email protected], fax it to 651-201-5501, or mail it to: MnVFC Program, PO Box 64975, St. Paul, MN 55164-0975.
This is your only opportunity to request MnVFC influenza vaccine. Delivery information will be sent when it becomes available later this year. MDH cannot guarantee that
your entire order will be filled becuase this order is submitted after the prebook deadline of Jan. 29, 2016.
No, I do not wish to prebook MnVFC influenza vaccine for the 2016-17 season.
Date:
Site name:
Contact name:
Email (will receive flu vaccine delivery information):
Type
Inactivated injectable
Inactivated injectable
Influenza vaccine
Fluzone Quadrivalent
(sanofi pastuer)
FluLaval Quadrivalent
(GSK)
MnVFC PIN:
Telephone:
Dose
Doses
ordered
6 months through 35 months ONLY
0.25ml
Currently
unavailable**
36 months and older
0.5ml
10 pre-filled syringes
6 months and older
0.5ml
1 multi-dose vial of 10 doses
36 months and older
0.5ml
1 multi-dose vial of 10 doses
Age indications
Packaging
10 pre-filled syringes
Preservative-free or
thimerosal-free*
Thimerosal-free,
preservative-free
Contains thimerosal
preservative
Contains thimerosal
preservative
*All MDH influenza vaccine products are thimerosal-free except two. Be sure to order enough thimerosal-free vaccine to provide it for parents requesting it. If you prefer to receive a different brand of flu
vaccine than is listed on the order form, send an email to [email protected].
**Fluzone 0.25ml pre-filled syringes are currently on backorder. We expect to have more supply available in late January or early February 2017.
This order form must be signed by a licensed practitioner who is authorized to procure vaccine/biologicals according to Minnesota Statutes, Section 151.37 (e.g., M.D.,
D.O., nurse practitioner, physician’s assistant, or pharmacist). Please include the individual’s title.
Name and title (M.D., D.O., N.P., P.A., or R.Ph. only) ______________________________________________________________________________
 By checking this box, I attest that the completed order form is accurate and that I am a licensed practitioner who is authorized to procure vaccines/biologicals
according to Minnesota Statutes.
 By checking the box, I attest that I have the authority to complete this vaccine order form on behalf of the "Prescribing Professional" on this form whose signature is
on file at our site as required by state law.
1/17