Scdhu Fax

Confidentiality Notice: The contents of the document(s) accompanying this facsimile transmission are confidential and intended only for use by the individual(s) named above. [...] It may contain information that is privileged, confidential, or otherwise protected from disclosure. [...] Any review, dissemination or use of this transmission or its contents by persons other than the addressee is strictly prohibited. [...] Facility Fax #: Facility Name: # of Fridges: Type: □ Bar □ Domestic □ Purpose Built • Place orders by Wednesday 3 pm for pick up the following Wednesday • Coolers must be between 2 - 8 ᴼC for vaccine to be released • Orders must include the previous 4 week temperature log for all fridges • Vaccine order inquiries ext. [...] 8808 REFER to the PUBLICLY FUNDED IMMUNIZATION SCHEDULES FOR ONTARIO (June 2022) for # of eligible doses and intervals between doses (product specific tables noted below). [...] Initials (First. Last): ________________________ DOB (YYYY/MM/DD): _____________________________ Vaccine Name Product / Description Dose # in Series Requested Eligibility Criteria (check all that apply) Bexsero® Meningococcal B (4CMenB) Dose: 1 2 3 4 (See Table 14) Age 2 months through 17 years*: Functional or anatomic asplenia Complement, properdin [...] Location to be picked up (please check): Gravenhurst Huntsville Orillia VIM Order # (for office use only):Confidentiality Notice: The contents of the document(s) accompanying this facsimile transmission are confidential and intended only for use by the individual(s) named above. [...] It may contain information that is privileged, confidential, or otherwise protected from disclosure. [...] Any review, dissemination or use of this transmission or its contents by persons other than the addressee is strictly prohibited. [...] Location to be picked up (please check): Gravenhurst Huntsville Orillia VIM Order # (for office use only): 2024-01-25