Public Health Department Resource Order Form

Date: Organization:
Name: Address:
City: State:   Zip:
Phone: Fax:

Please order the exact quantities sufficient for a three-month period English Spanish
Record Cards Adult Record Card  
Pink USIR (cards may be ordered individually. Printable card link
below.) Due to increased demand, your USIR order will be adjusted
as necessary.
 
Lifetime Personal Record (Yellow Card)  
Schedule Cards Adolescent
Adult
Childhood
Childhood 8.5 x 11
Other Materials Pertussis Cards Surround your Baby double-sided English/Spanish  
Pertussis Cards Surround your Loved Ones double-sided
English/Spanish
 
Pertussis Tear Pads Surround your Baby double-sided
English/Spanish
 
Pertussis Tear Pads Surround your Loved Ones double-sided
English/Spanish
 
Pertussis Tear Pad Stands  
Perinatal Hepatitis B Lab Testing Form - 2010 version  
International Certificate of Vaccination (ICV)  
Plastic Sleeves for ICV  
Plastic Sleeves  
Next Due Stickers (250 per pad)  
PPV Stickers (500 per roll)  
VFC Stickers (100 per roll)  
Exemption Forms Personal  
Religious  
Posters Adult Immunization/You Never Outgrow Vaccinations 11 x 17
Adult Schedule Poster 11 x 17
Back to School Imm Requirements Poster 11 x 17  
Got Vaxed Poster Question Mark 14 x 20  
Got Vaxed Poster Teenagers 14 x 20  
Get the Flu Vaccine Poster 11 x 17
Pertussis Surround your Baby 11 x 17
Preteen Doctor Visit 12 x 20
Vaccinate Before you Graduate 11 x 17  
Brochures Get the Flu Vaccine
Hepatitis A What You Should Know
Older Adults Need Shots
Planning a Trip  
Preteen Doctor Visit
Protect Children by Protecting Yourself
The Utah School Immunization Rule
Vaccinate Before you Graduate
Vaccine Safety
Tearpads VFC Information Tearpad double-sided English/Spanish  
Please verify your order by entering the random letters (case sensitive) displayed in this image:

Contact Tammy Gresham with any questions (801) 538-9450. Include exact quantities sufficient for a three-month period. Due to limited inventory, your order may be adjusted.
PLEASE ALLOW 1-2 WEEKS FOR DELIVERY

Printable Pink Card here: USIR Pink Card