Pediatric Vaccine Order Form - Missouri Department Of Health And Senior Services
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1V
C
P
ACCINES FOR
HILDREN
ROGRAM
Pediatric Vaccine Order Form
To ensure the vaccine order is processed as quickly as possible, all sections of this form MUST be completed. Fax the Vaccine Order Form, Vaccine Accountability Form
and monthly Temperature Logs to 573.526.5220. All vaccine transfers and wastage should be submitted at the time of the occurrence.
Vaccine
Brand
Unit Shipping Size
Doses Requested
NDC #
Daptacel
10x1 dose vials
49281-0286-10
Sanofi
DTaP
10x1 dose vials
58160-0810-11
Infanrix
GSK
10x1 dose syringes
58160-0810-52
10x1 dose vials
58160-0812-11
Kinrix
DTaP/IPV
GSK
10x1 dose syringes
58160-0812-52
Pediarix
10x1 dose syringes
58160-0811-52
DTaP/Hepatitis B/IPV
GSK
DTaP/IPV/Hib
Pentacel
5x1 dose vials
49281-0510-05
Sanofi
e-IPV
IPOL
10 dose vials
49281-0860-10
Sanofi
10x1 dose vials
00006-4831-41
Vaqta
Merck
10x1 dose syringes
00006-4095-02
Hepatitis A
10x1 dose vials
58160-0825-11
Havrix
GSK
10x1 dose syringes
58160-0825-52
10x1 dose vials
58160-0820-11
Engerix B
GSK
10x1 dose syringes
58160-0820-52
Hepatitis B
10x1 dose vials
00006-4981-00
Recombivax
Merck
10x1 dose syringes
00006-4093-02
10x1 dose vials
PedvaxHIB
00006-4897-00
Merck
Hib
5x1 dose vials
ActHIB
49281-0545-05
Sanofi
HPV- 9 Valent
Gardasil 9
10x1 dose vials
00006-4119-03
Merck
HPV-Quadrivalent
Gardasil
10x1 dose vials
00006-4045-41
Merck
HPV- Bivalent
Cervarix
10x1 dose syringes
58160-0830-52
GSK
Menactra
5x1 dose vials
49281-0589-05
Sanofi
Meningococcal Conjugate
Menveo
5x1 dose vials
46028-0208-01
Novartis
Pneumococcal Conjugate
Prevnar 13
10x1 dose syringes
00005-1971-02
Pfizer
Pneumococcal Polysaccharide
Pneumo-23
1 dose vial
00006-4943-00
Merck
10x1 dose tubes
00006-4047-41
RotaTeq
Merck
Rotavirus
25x1 dose tubes
00006-4047-20
Rotarix
10x1 dose vials
58160-0854-52
GSK
1 dose vials
49281-0215-10
Td
Tenivac
Sanofi
1 dose syringe
49281-0215-15
10x1 dose vials
58160-0842-11
Boostrix
GSK
10x1 dose syringes
58160-0842-52
Tdap
10x1 dose vials
49281-0400-10
Adacel
Sanofi
5x1 dose syringes
49281-0400-15
VACCINES STORED IN THE FREEZER
MMR
MMR-II
10x1 dose vials
00006-4681-00
Merck
MMRV
Proquad
10x1 dose vials
00006-4171-00
Merck
Varicella
Varivax
10x1 dose vials
00006-4827-00
Merck
SPECIAL ORDER VACCINE
CONTACT VFC PROGRAM FOR APPROVAL
DT
DT
1 dose vial
49281-0225-10
Sanofi
HibMenCY-TT
MenHibrix
1 dose vial
58160-0801-11
GSK
1 dose syringe
46028-0114-02
Bexsero
Novartis
Meningococcal Group B
10x1 dose syringes
46028-0114-01
Trumenba
10x1 dose syringes
00005-0100-10
Pfizer
ADDITIONAL DOSES REQUESTED FOR (Please check appropriate box below)
Back to School
Disease Outbreak
Other ___________________________________________
PIN
Provider/Clinic Name
DELIVERY
Check all days and times the
Tuesday From _____ To _____ (Closed for Lunch From: _____ To _____)
Thursday From _____ To _____ (Closed for lunch From _____ To _____)
facility may receive vaccine. If closed
Wednesday From _____ To _____ (Closed for Lunch From _____ To _____)
Friday From _____ To _____ (Closed for lunch From _____ To _____)
.
during lunch hour, please specify
Missouri Department of Health and Senior Services
Bureau of Immunization Assessment and Assurance 930 Wildwood Drive Jefferson City, MO 65109
800.219.3224 Fax: 573.526.5220
Rev 7-15
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