Immunization Vaccine Order Form

Form Requisitions
A service for private physicians

Please complete the following form and click the "Submit" button when you have finished. You must enter an email address for the requisition to be filled.  All fields are required to place your order. All forms are available in packs of 100 each. In the "Quantity" field, indicate the number of packs you need. If you have any questions about the forms we offer, please call 1-800-469-4599. Thank you.





Contact Person   




(We cannot ship to a P.O. Box)

           Area Code -

Are you a participant in the Vaccines For Children Program?  Yes    No

Quantity 

  Alabama Certificate of Immunization, a.k.a. "Blue Slip," IMM 50 (Limit 20 packs)
  Alabama Certificate of Immunization, IMM 50w (Limit 20 packs)
  Alabama Immunization Record Card,  IMM 105 (plastic covers not available)
  VFC Patient Eligibility Screening Form, IMM 503
  VFC Vaccine Stickers (Please specify number of stickers)
  Vaccine Recall/Reminder Refill Cards (packs of 100)
   Monthly Temperature Charts (Fahrenheit) (1 dozen)
   Monthly Temperature Charts (Celsius) (1 dozen)

E-mail address to receive order confirmation (This field is required):

      

                                                                                                                                Revised 01/07