2015-2016 Flu Vaccine Order Form
2015/16 Flu Vaccine Order Form Customer Information Name: ! ! Address: ! ! City: ! ! ! Phone: ! ! State License #:! ! ! State: ! ! ! ! DEA License #: ! ! Email: ! ! Purchase Order #: ! ! Zip: ! Fax: ! Customer Signature: Date: *Person signing this order form represents that they are authorized to sign on Pack Size Manufacturer Age Indication Preservative Free Afluria 5ml MDV - TIV 10 Dose Vial bioCSL 5 Years+ No Call Afluria 0.5ml PFS - TIV 10 Pack-PFS bioCSL 5 Years+ Yes Call Flulaval 5ml MDV - QIV 10 Dose Vial GSK 3 Years+ No Call Fluvirin 5ml MDV - TIV 10 Dose Vial Novartis 4 Years+ No Call Fluvirin 0.5ml PFS - TIV 10 Pack-PFS Novartis 4 Years+ No Call Flucelvax 0.5ml PFS - TIV 10 Pack-PFS Novartis 18 Years+ Yes Call Fluzone 5ml MDV - TIV 10 Dose Vial Sanofi 6 Months+ No Call Fluzone 0.5ml PFS High-Dose - TIV 10 Pack-PFS Sanofi 65 Years+ Yes Call Fluzone Intradermal 0.1ml PFS - TIV 10 Pack-PFS Sanofi 18-64 Years Yes Call 10 Vials Sanofi 36 Months+ Yes Call Fluzone 5ml MDV - QIV 10 Dose Vial Sanofi 6 Months+ No Call Fluzone 0.25ml Pediatric PFS - QIV 10 Pack-PFS Sanofi 6-35 Months Yes Call Fluzone 0.5ml PFS - QIV 10 Pack-PFS Sanofi 36 Months+ Yes Call Flu Vaccine Brand Name Fluzone 0.5ml SDV - QIV QTY Price* MDV = Multi-Dose Vial - SDV = Single-Dose Vial - PFS = Pre-Filled Syringe - QIV = Quadrivalent - TIV = Trivalent Phone: 818-997-8846 Fax: 818-997-8850 Email: [email protected] Website: www.nmsincusa.com *Price Includes Federal Excise Tax - Volume Discounts Available I have ordered the above quantity and agree to the terms. A copy of a DEA Registration, State Physician License or a State Pharmacy License is required to be on file with Nationwide Medical/Surgical before your order can be shipped. Nationwide Medical/Surgical ships based on availability from the manufacturer. Nationwide Medical/Surgical will not be held liable for delays or product shortage. In no event shall Nationwide Medical/Surgical be liable to customers for incidental, special or consequential damages from any cause, including without limitation, damages resulting from any unavailability of, defect in, or mis-shipment of products. Pharmaceuticals purchased from Nationwide Medical/Surgical are non-returnable. If you wish to be removed, please call 800-997-8846 or fax 818-997.8850. All items subject to manufacturer price increase/availability.
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