2014-2015 Flu Vaccine Pre-book form

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					                                                                              McKesson Medical-Surgical Inc.
                                                                        2014 / 2015 Flu Vaccine Pre-Booking Form

                Account Number*


Ship-to Account Number*


                Customer Name*

               Customer Address*

                Customer City/St*                                                                                      Customer Zip*

                            District                                                 Customer P.O. Number

                            Phone*                                                                           Fax

                Account Manager                                                             Customer Email*



                                                                                                                                             Preservative           Total Qty of          Total Doses
                         Mfg.                          Description                          Age Range              Doses / Vial or Box
                                                                                                                                               Content             Vials or Boxes           Ordered

                         GSK                        FluLaval® 5mL Vial                     3 yrs and above               10 / Vial                 Yes                                           0
                        Novartis                    Fluvirin® 5mL Vial                    4 years and above              10 / Vial                 Yes                                           0
                                                       Fluvirin® 0.5mL                                                                     No (1 mcg / 0.5 mL
                       Novartis                 Prefilled Luer Lock Syringe
                                                                                          4 years and above              10 / Box
                                                                                                                                                 dose)
                                                                                                                                                                                                 0
Trivalent




                       Novartis            Flucelvax® 0.5mL Prefilled Syringe            18 years and above              10 / Box                 None                                           0

                         CSL                         Afluria® 5mL Vial                    9 years and above              10 / Vial                 Yes                                           0
                                                       Afluria® 0.5mL
                         CSL
                                                      Prefilled Syringe
                                                                                          9 years and above              10 / Box                 None                                           0
                                                                                       6 - 35 months (0.25mL)
                        Sanofi                      Fluzone® 5mL Vial
                                                                                       3 yrs and above (0.5mL)
                                                                                                                         10 / Vial                 Yes                                           0
                                                    Fluzone® 0.5mL
                        Sanofi
                                                    Prefilled Syringe
                                                                                           3 yrs and above               10 / Box                 None                                           0
                                               Fluzone® High-Dose 0.5mL
                        Sanofi
                                                    Prefilled Syringe
                                                                                         65 years and above              10 / Box                 None                                           0
                        Sanofi                    Fluzone® Intradermal                       18-64 years                 10 / Box                 None                                           0

                                                  FluMist® Quadrivalent
                     MedImmune                                                                 2-49 yrs                  10 / Box                 None                                           0
Quadrivalent




                                              (Influenza Vaccine Live, Intranasal)


                          GSK                FluLaval® Quadrivalent 5mL Vial               3 yrs and above               10 / Vial                 Yes                                           0
                                                                                       6 - 35 months (0.25mL)
                        Sanofi              Fluzone® Quadrivalent 5 mL Vial
                                                                                       3 yrs and above (0.5mL)
                                                                                                                         10 / Vial                 Yes                                           0
                                        Fluzone® Quadrivalent 0.5 mL Prefilled
                        Sanofi
                                                      Syringe
                                                                                           3 yrs and above               10 / Box                 None                                           0
                                         Fluzone® Quadrivalent 0.5 mL Single           6 - 35 months (0.25mL)
                        Sanofi
                                                     Dose Vial                         3 yrs and above (0.5mL)
                                                                                                                         10 / Box                 None                                           0
                                        Fluzone® Quadrivalent 0.25 mL Prefilled
                        Sanofi
                                                 Syringe (Pediatric)
                                                                                            6 - 35 months                10 / Box                 None                                           0
                                                                        Total Flu Vaccine Prebook                                                                                   0                       0
                  *All Sell Prices include federal excise tax of $0.75 per dose of $7.50 per vial or box of ten.


                                                                                     All Flu Vaccine is non-returnable
                                                                 All prebooks not cancelled by July 15, 2014 automatically turn into orders.

                                                                                                          Terms of Sale
                  Prices are subject to change without prior notification. Neither McKesson Medical-Surgical nor any of its affiliates guarantee any specific delivery date or quantity. Neither McKesson
                  Medical-Surgical nor any of its affiliates will be held liable for any delays or product shortages.
                  You agree that this is a binding order which may only be cancelled by delivering McKesson written notice of cancellation prior to July 15, 2014. By placing this order, you agree to
                  purchase the above designated Flu Vaccine upon delivery. You further agree that McKesson may substitute products at the same sales price as long as the substitute product has an
                  equal or greater age indication and is provided in the same form. This order for Flu Vaccine may be canceled if McKesson fails to deliver the Flu Vaccine by November 15, 2014. The
                  sales price indicated above includes freight unless separately identified on the invoice. McKesson's standard terms of sale apply to this order for Flu Vaccine, except that Flu Vaccine
                  when shipped is not returnable.
                  IN NO EVENT SHALL MCKESSON BE LIABLE FOR INCIDENTAL, SPECIAL, OR CONSEQUENTIAL DAMAGES, WHETHER BASED ON BREACH OF CONTRACT, WARRANTY,
                  TORT, PRODUCT LIABILITY, OR OTHERWISE, (INCLUDING LOST PROFITS) FROM ANY CAUSE, INCLUDING, WITHOUT LIMITATION, DAMAGES RESULTING FROM ANY
                  UNAVAILABILITY OF, DEFECT IN, OR MISSHIPMENT OF PRODUCTS OR THE PROVISION OF SERVICES, AND WHETHER OR NOT MCKESSON HAS BEEN ADVISED OF THE
                  POSSIBILITY OF SUCH DAMAGE. this document in its entirety and agree to the terms and
                  I acknowledge that I have read                                                                                            Name*
                  conditions stated herein. I am authorized to order flu vaccines on behalf of this practice. I
                  further consent to receiving fax communications from McKesson at any of the company's
                                                                                                                                            Signature*
                  business fax numbers.                                                                                                     Date *

                   Please list any days or times that your office will not be able to accept deliveries
                                                    for flu vaccine:

				
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