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RSV Vaccine Order - (LTCH/RH) Elgin St. Thomas

24hours of notice are required to allow for planning. Orders will be processed daily.

Please order conservatively and strategically to make the most of each vial and to prevent wasteage.

Please ensure you have submitted your weekly fridge monitoring temperatures by fax to 519-633-0468.

Today's Date

Facility Name

Contact Name:

Telephone Number:

Email Address:

How many DOSES (residents with consent ONLY) of RSV vaccine do you require? (Note: These are MULTI-DOSE vials of 10 doses each. Only a small number of single dose vials are available – so be specific on numbers)

When do you plan to pick up the vaccine?

When do you plan to administer the vaccine?

Do you require SWPH's assistance on your vaccination day (to help with reconstituting vaccine, labelling vaccine, etc.)?

Yes

Do you have any further comments or questions about your vaccine supply?

Forms

RSV Vaccine Order - (LTCH/RH) Elgin St. Thomas