National Immunisation Program Vaccines_1_

							                  GOVERNMENT FUNDED VACCINE ORDER FORM
                                                                                                  DHS ACCOUNT
    ORDER TO:
                                                                                                    NUMBER:
    Em a i l : i m m u n i s a t i o n @ d h s. v i c . g ov . a u
    FAX: 1300 768 088

    In order to receive Government funded vaccines, I agree that this centre complies
    with the recommended vaccine cold chain storage of 2º-8ºC as stated in the National
    Vaccine Storage Guideline, Strive for 5: www.immunise.health.gov.au

    Signature of authorised person:                                        Print name:


    Centre name:

    Phone number:                                                    Fax number:

    Delivery address:

                           ONLY STORE A MAXIMUM ONE MONTH OF STOCK ON HAND

                                                                                            No. Doses    No. Doses
National Immunisation Program Vaccines                                       Brand
                                                                                            in Stock     Required
Diphtheria, Tetanus, Acellular Pertussis & Inactivated Poliomyelitis
                                                                             Infanrix IPV
(2, 4, 6 months and 4 years)

Oral Rotavirus (2, 4 and 6 months)                                           RotaTeq

Childhood Pneumococcal (2, 4 and 6 months)                                   Prevenar

Haemophilus influenzae type b & Hepatitis B (2, 4 and 12 mths)               Comvax

Meningococcal C (12 months)                                                  NeisVacC

Measles, Mumps, Rubella (12 months and 4 years)                              Priorix

Varicella (18 months & Year 7 School catch-up program)                       Varilrix

HPV (females in school program and aged 18-26 years)                         Gardasil

                                                                             Adult
Hepatitis B (Year 7 school catch-up program)
                                                                             HB Vax II
Adolescent Diphtheria, Tetanus & acellular Pertussis
                                                                             Boostrix
(Year 10 school program)

Adult Diphtheria & Tetanus Adsorbed (50 year old booster)                    ADT Booster

Influenza (Annual)                                                           As supplied

Pneumococcal Pneumonia (See handbook for recommendation)                     Pneumovax 23

Vaccines required for special circumstances                                                 No. Doses    No. Doses
                                                                             Brand
*Call DHS: 1300 882 008 to discuss                                                          in Stock     Required
                                                                             Paediatric
Hepatitis B Paediatric (Maternity hospitals for neonates)
                                                                             HB Vax II

Human Tuberculin – Tubersol 1ml vial (approx 10 tests)                       PPD

Poliomyelitis inactivated - *spoken with:                                    IPOL*

Haemophilus influenza type b – *spoken with:                                 PedvaxHIB*


    - Please allow a MINIMUM of 3 business days for processing & delivery of your vaccine order
    - Orders will not be filled unless ‘No. of Doses in stock’ colum n is completed
    - Order form available on website – www.health.vic.gov.au/immunisation
    - Vaccine delivery enquiries: 1800 008 275 (CSL Parkville)
    - For other enquiries phone: 1300 882 008