PRIVATE PROVIDER RESOURCE ORDER FORM
Name: Organization: Address: City:	Date: Phone: Fax: State:   Zip:

Please order the number of packages needed:		English	Spanish
Record Cards	Adult Record Card (50)
	Pink USIR (250)
	Lifetime Personal Record (Yellow Card) (50)
Schedule Cards	Adolescent (Temporarily out of stock) (100)
	Adult (100)
	Childhood (100)
	Childhood 8.5 x 11 (50)
Other Materials	Plastic Sleeves (100)
	Next Due Stickers (250 per pad)
	PPV Stickers (500 per roll)
	VFC Stickers (100 per roll)
Exemption Forms	Medical (50)
Posters	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
	Preteen Doctor Visit 12 x 20
Brochures	Get the Flu Vaccine (50)
	Got Vaxed Adolescent (100)
	Hepatitis A What You Should Know (50)
	Hepatitis B Stop the Spread (50)
	Older Adults Need Shots (100)
	Planning a Trip (100)
	Preteen Doctor Visit (100)
	Protect Yourself Adult (100)
	Questions & Answers (25)
	USIIS Parent's Guide (100)
	Utah School Immunization Rule (100)
	Vaccinate Before You Graduate (100)
	Vaccine Safety (50)
Tearpads	VFC Information Tearpad (English and Spanish combined) (50)
Please verify your order by entering the random letters (case sensitive) displayed in this image:
Contact Lisa Young with any questions (801) 538-9101 or email Include quantities that will be sufficient for a three month period. PLEASE ALLOW 2-3 WEEKS FOR DELIVERY

Back to Top

Home | Public Information | Provider Information | Events Calendar
Newsletter | Contact | Sitemap | Help | Disclaimer | Privacy Policy

© Copyright 2001 Immunization Program Utah Department of Health
All rights reserved