Chpvpd 002 1 2026

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4.8 out of 5

132 votes

The document is a Healthcare Provider Requisition Form for vaccines from the Leeds Grenville & Lanark District Health Unit. It outlines the process for healthcare providers to order vaccines, including required information, shipping instructions, and eligibility criteria. The form emphasizes maintaining proper vaccine storage temperatures and includes a list of available vaccines with their respective catalogue numbers and dosage requirements.

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Click ‘Get Form’ to open the Healthcare Provider Requisition Form for Vaccines in the editor.
Begin by filling in your Healthcare Provider Code and Name at the top of the form. Ensure accuracy to avoid processing delays.
Enter the Requisition Date in the format yyyy/mm/dd, followed by your contact details including Last Name, First Name, Title, Telephone No., Fax No., and Email Address.
Complete the Ship to Address section with Unit No., Street No., Street Name, City/Town, PO Box, STN/RPO/RR, Province, and Postal Code.
In the Shipping Instructions section, select your preferred Health Unit Office for delivery.
List the vaccines you require by entering their descriptions, doses on hand, doses per package, catalogue numbers, and doses required in the corresponding fields.
Finally, review all entries for completeness. Sign and date at the bottom of the form to verify compliance with temperature maintenance requirements before submitting via fax or email.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (132 Votes)
2015	4.4 Satisfied (229 Votes)

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