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2024-2025 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.
FluLaval SYR; 10-pack (TIV) (6 mths and older) (PF)
Afluria SYR; 10-pack (TIV) (3 yrs and older) (PF)
Afluria MDV10; 1-pack (TIV) (3 yrs and older)
Fluzone SYR; 10-pack (TIV) (6 mths and older) (PF)
Fluzone MDV10; 1-pack (TIV) (6 mths and older)
FluMist SPRAYER; 10-pack (TIV) (2 yrs and older)
Flucelvax SYR; 10-pack (TIV) (6 mths and older) (PF)
Flucelvax MDV10; 1-pack (TIV) (6 mths and older)
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