Private Provider 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 (No longer available. Printable card link below - can
be printed on any color paper.)
   
Lifetime Personal Record (Yellow Card)  
Schedule Cards Adolescent
Adult
Childhood
Childhood 8.5 x 11  
Other Materials 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  
Plastic Sleeves  
Next Due Stickers (250 per pad)  
PPV Stickers (500 per roll)  
VFC Stickers (100 per roll)  
HPV Parent Tear Pad double-sided English/Spanish (50 per pad)  
Posters Adult Immunization/You Never Outgrow Vaccinations 11 x 17
Adult Schedule Poster 11 x 17
Got Vaxed Poster Question Mark 14 x 20  
Got Vaxed Poster Teenagers 14 x 20  
Get the Flu Vaccine 11 x 17  
Pertussis Surround your Baby 11 x 17  
Preteen Doctor Visit 12 x 20
Brochures Get the Flu Vaccine
Got Vaxed Adolescent
Hepatitis A What You Should Know
Older Adults Need Shots
Planning a Trip
Preteen Doctor Visit
Protect Children by Protecting Yourself
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