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Vaccine Order Form

Telephone: 613-580-6744
Completed orders may be submitted online or sent via email or fax.
Email: vaccine@ottawa.ca Fax: 613-580-2783

ATTENTION: All information below must be completed clearly. Please indicate doses on hand when placing a Vaccine Order.

Please submit your monthly temperature log when placing a Vaccine Order. Please allow 2-3 working days to process your order.

For age and high-risk criteria, please refer to the Publicly Funded Immunization Schedules for Ontario-June 2022.

Date: (dd/mm/yyyy)

Contact Person:

Doctor/Clinic:

Address:

Name of Courier:

Telephone Number:

Send me a confirmation email for this request.

Yes

Please submit your monthly temperature log when placing a vaccine order (you can either browse and upload your file(s) below or fax to 613-580-2783 - write Physician/Clinic name and address on each copy faxed)

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Check off the vaccines you would like to order (Note: The following vaccines must be pre-authorized)

Haemophilus influenzae b

Hepatitis B

Additional supplies you would like to order (select all that apply)

Immunization cards with plastic sleeves

Ottawa Public Health Immunization Reporting Postcards

Temperature log book

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Vaccine Order Form

Additional supplies you would like to order (select all that apply)

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