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2023-2024 INFLUENZA VACCINE ORDER FORM ALABAMA VACCINES FOR CHILDREN PROGRAM
Request for additional VFC Flu doses. Please notes that orders will be filled according to the availability of the flu presentation that are on hand.
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Today's Date
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VFC Site Name
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Contact Person
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VFC PIN
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Shipping Address
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City
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State
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Zip Code
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Phone #
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Email Address
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Special Delivery Instructions (e.g. days/hours closed)
Please email vfc@adph.state.al.us with any questions.
Please indicate the vaccine presentation you prefer. If preferred presentation is not available, you will receive what is available. PLEASE ENTER THE NUMBER OF DOSES IN 10 DOSE INCREMENTS IN THE SPACES PROVIDED.
If the vaccine presentation that I requested is not available, I agree that another presentation can be substituted in its place.
Fluzone Quad (Age 6 mths and older) Multi-dose vials
Fluzone Quad (6 mths and older) No Preservative - 10 single dose syringes
Fluarix Quad (6 mths and older) No Preservative -10 single dose syringes
Flucelvax Quadrivalent (6 mths and older) - 10 Single dose syringes
FluLaval Quadrivalent (6 mths and older) No Preservative - 10 Single dose syringes
FluMist Quadrivalent (2 yrs and older) No Preservative - 10 Single dose sprayer
Afluria Quadrivalent (6 mths and older) No Preservative - 10 single dose syringe
Afluria Quadrivalent (6 mths and older) No Preservative - 10 multi-dose vials
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