ATTN: Immunization Program
Kent County Health Department, Central Supply - Lower Level
700 Fuller NE, Grand Rapids, MI 49503
Phone: (616) 632-7007 FAX: (616) 632-7299
2016 SUPPLY ORDER FORM
Date:
Practice Name:
Contact Name:
Direct Phone & Extension:
Fax:
Email Address: ______________________________________________________________________
Complete order form and fax it to us at 632-7299. You will be contacted when your order is ready.
Pick up location: Kent County Health Department, 700 Fuller Ave. NE- Central Supply entryway table.
Please order in quantities of 10- maximum quantity of 500 each
Qty
Type
Unavailable
Card
Card
Form
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Supply Description (English only)
Green Immunization Record Cards (Wallet Size)
White Immunization Record Cards (Signature Card)
Health Appraisal Form
DTaP
Hepatitis A (Hep A)
Hepatitis B (Hep B)
Hib
Human Papillomavirus - Cervarix (HPV2)
Human Papillomavirus - Gardasil (HPV4)
Human Papillomavirus - Gardasil (HPV9) NEW
Meningococcal ACWY (MCV4 / MPSV4)
Serogroup B Meningococcal
MMR
MMRV
Mult-Vaccine (DTaP, IPV, Hib, Hep B, PCV-13, Rotavirus)
Pneumococcal Conj (PCV-13)
Pneumococcal Poly (PPSV)
Polio-Inactivated (IPV)
Rabies
Rotavirus (RV1 / RV5)
Tdap
Td
Typhoid
Varicella (chickenpox)
Yellow Fever
Zoster (shingles)
Revision Date
08/2010
01/2011
07/2009
05/17/2007
07/20/2016
07/20/2016
04/02/2015
05/03/2011
05/17/2013
12/02/2016
03/31/2016
08/09/2016
04/20/2012
05/21/2010
11/05/2015
11/05/2015
04/24/2015
07/20/2016
10/06/2009
04/15/2015
02/24/2015
02/24/2015
05/29/2012
03/13/2008
03/30/2011
10/06/2009
VIS' on back order, Influenza and Foreign Language VIS forms can be printed from
www.michigan.gov/vaccines
S:\CLINIC.SHR\SUPER.SHR\Immunizations\Vaccines\Vaccine Information Statement\KCHD VIS and provider
order forms Rev 12-09-2016