NM VFC Ordering & Inventory Form
Facility: VFC Pin#: Days and Hours of Operation
AM PM
Delivery Address: Prepared by: M to M to
Tu to Tu to
City: Phone#: W to W to
Zip Code: Date Submitted: Th to Th to
************ ____ Check here if this is a new address EMAIL: F to F to
FAX: _______ Check here if these days/hours represent a
*********** special closure this month only
VACCINE LIST Brand Presentation Doses Complete Inventory Required
Doses on
Name (Subject to change depending Expiration
Requested on product availability) Hand Lot Numbers
Dates
Daptacel Single dose vials-10 per box
DTaP Single dose vials-10 per box
Infanrix
Single dose syringes-10 per box
DTaP-Hep B-IPV Pediarix Single dose syringes-5 per box
DTaP-IPV-Hib Pentacel Single dose vials-5 per box
Single dose vials-10 per box
DTaP- IPV Kinrix
Single dose syringes-5 per box
Single dose vials-10 per box
Havrix
Hep A Single dose syringes-10 per box
Vaqta Single dose vials-10 per box
Single dose vials-10 per box
Engerix
Single dose syringes-10 per box
Hep B
Recombivax Single dose vials-10 per box
Hib/4d ActHib Single dose vials-5 per box
Hib/Booster dose Hiberix Single dose vials-10 per box
Hib/3d PedvaxHib Single dose vials-10 per box
Single dose vials-10 per box
Cervarix
HPV Single dose syringes-5 per box
Gardasil Single dose vials-10 per box
Menactra Single dose vials-5 per box
MCV
Menveo Single dose vials-5 per box
MMR MMR-II Single dose vials-10 per box
MMRV ProQuad Currently not available
PCV (Pneumococcal Prevnar Single dose syringes-10 per box
_ conjugate)
Polio IPV Ipol Single dose syringes-10 per box
PPSV (Pneumococcal Pneumovax Single dose vials–10 per box
_ polysaccharide)
Rotavirus RV1/2d Rotarix Single dose vials-10 per box
Rotavirus RV5/3d RotaTeq Single dose tubes-10 per box
Td (7-10 years only) Decavac Single dose syringes-10 per box
Single dose vials-10 per box
Tdap (10-18 years) Boostrix
Single dose syringes-5 per box
Varicella Varivax Single dose vials-10 per box
Email completed form to: vaccine.orders@state.nm.us FAX completed order to: 505-827-1741 or 505-827-1064
Download this form at: www.immunizenm.org/provider/documents/vaccineorderandinventoryform-may10_000.doc 05/10