Influenza Vaccine Order Form

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The information collected on this form will be used to allow the creation of materials for the Immunization Program. The information is collected under the authority of and managed in accordance with the Freedom of Information and Protection of Privacy Act, R.S.P.E.I. 1988, Cap. F-15.01. If you have any questions about the collection, use or disclosure of your personal information, please contact the Immunization Coordinator at the Chief Public Health Office at 902-368-4996.

Identification

Provide contact details for the practice, clinic, long term care or community care facility below.

Business/Organization Name

Contact First Name

Contact Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

Example: C1B 0X1 or 12345

Country

Telephone 1

For example: 902-555-5555

Telephone 2

For example: 902-555-5555

Fax Number

For example: 902-555-5555

Email Address

Are you the immunizer or the person ultimately responsible for the vaccines as per the Influenza Immunization Policy?

Additional Contact Information

Provide contact details for the immunizer or person responsible for the vaccines below.

First Name

Last Name

Telephone

For example 902-555-5555

Email Address