H1N1 vaccine order form
Questions marked with an asterisk (*) are mandatory.
1

* Name of Facility:
2

* County:
3

* Point of Contact Name:
4

* Phone Number:
5

* Fax Number:
6

* Email (if you do not have one please indicate with n/a):
7

* Please specify how many DOSES of each presentation listed below you would like to order.  If you do not want any DOSES, please put a zero next to that presentation.  Each presentation of vaccine must be ordered in quantities of 100 doses.  Please note that there is no longer any 0.25mL presentation for ordering.

# of DOSES of Nasal Spray
# of DOSES of Prefilled 0.5mL
# of DOSES of Multi-dose vial 5mL