2016-17 UUAV 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: UUAV Program, PO Box 64975, St. Paul, MN 55164-0975.
This is your only opportunity to request UUAV 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 UUAV influenza vaccine for the 2016-17 season.
Date:
Site name:
Contact name:
Email (will receive flu vaccine delivery information):
Influenza vaccine
Age indications
MnVFC PIN:
Dose
Doses
ordered
Telephone:
Packaging
Preservative-free or
thimerosal-free
Fluzone Quadrivalent
6 months and older
0.5ml
1 multi-dose vial of 10 doses
Contains thimerosal
preservative
FluLaval Quadrivalent
36 months and older
0.5ml
1 multi-dose vial of 10 doses
Contains thimerosal
preservative
(sanofi pastuer)
(GSK)
If you prefer to receive a different brand of flu vaccine than is listed on the order form, please send an email to [email protected].
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.
8/16