Delaware Immunization Program
Adult HPV Immunization Program Order Form

All vaccine orders placed on this form is for 19 - 26 years old female who do not have insurance or are underinsured. To use these vaccines for someone that is not eligible constitutes FRAUD.

Circle this section if you would like to have a receipt of your order faxed to you. You must fill out a fax number in order to receive a receipt.
Fax Number:(302) _________-____________

DELIVERY: CIRCLE all days and times you may receive vaccine. If closed during lunch hour, please specify.
   Monday         from: __________ to __________ Closed for lunch from __________ to __________
   Tuesday         from: __________ to __________ Closed for lunch from __________ to __________
   Wednesday    from: __________ to __________ Closed for lunch from __________ to __________
   Thursday        from: __________ to __________ Closed for lunch from __________ to __________
   Friday            from: __________ to __________ Closed for lunch from __________ to __________

VACCINE REQUEST
   1.  Date Submitted:___________________________________________

   2.  Name:__________________________________________________

   3.  PIN #:__________________________________________________ A

   4.  Telephone Number: (302) _________-____________

   5.  Vaccine & Brand (HPV "Gardasil"):____________________________

   6.  Packing (Single Dose Vials - 10 per Box:________________________

   7.  Doses Ordered:___________________________________________

   8.  **Current AHPV Inventory:__________________________________

   9.  Doses Given Since Last Order:________________________________

 10.  Expired/Wasted/Transferred Vaccines Code: E =Expired W = Wasted, T = Transferred
         Doses:__________ Code:__________

DELAWARE FORM REQUESTS
   Form: Vaccine Information Statement (VIS) English HPV
   Quantity (Circle): 50 or 100

   Form: Vaccine Information Statement (VIS) Spanish HPV
   Quantity (Circle): 50 or 100

   Form: Vaccination Schedule
   Quantity (Circle): 1 , 5 or 10

   Form: Adult HPV Immunization Program Order Form
   Quantity (Circle): 1 or 4

   Form: Immunization Reporting form (IR)
   Quantity (Circle): 50 or 100

   Form: White Return Envelopes
   Quantity (Circle): 5 or 10

   Form: Temperature Log Circle: C° or F°
   Quantity (Circle): 1 or 12

   Form: Adult HPV Immunization Program Patient Eligibility Form
   Quantity (Circle): 50 or 100

** Current inventory of Adult HPV Immunization Program vaccine is required. Orders will NOT BE FILLED unless this information is provided.

Vaccine orders may be faxed to 1-800-318-0810

If you have any questions regarding your orders, please call 1-800-282-8672 or (302) 744-1060

Rev 05/08