DELIVERY DATE: CLINIC DATE: CLINIC NAME: FACILITY NAME: SHIP TO ADDRESS: CITY: PROVINCE: CONTACT NAME: CELL: CELL: ARE SUPPLIES REQUIRED? YES NO If yes, Supply Order Form must be completed and sent. • Rural orders are delivered 48 hours prior to clinic, including weekends • Winnipeg orders are delivered day of the clinic (unless otherwise specified above) • Vaccines will only be released to the contact name(s) provided • Contacts must be reachable at phone numbers provided • Drivers will call 30 minutes prior to delivery and upon arrival VACCINE ORDERS MUST BE SUBMITTED AT LEAST THREE BUSINESS DAYS PRIOR TO CLINIC DATE OR SOONER DOSES REQUIRED IMPORTANT INFORMATION HOLDING POINT NUMBER: POSTAL CODE: ALTERNATE CONTACT NAME: DIRECT PHONE NUMBER: WEEKEND HOURS OF AVAILABILITY: Save form in PDF format and email to both: [email protected] [email protected] COVID VACCINE ORDER FORM Materials Distribution Agency 7-1715 St. James Street, Winnipeg, MB R3H 1H3 Ph: 204-945-3000 VACCINE TYPE: *Note: Pfizer vaccine is sent with corresponding amount of diluent
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DELIVERY DATE: CLINIC DATE:
CLINIC NAME:
FACILITY NAME:
SHIP TO ADDRESS:
CITY: PROVINCE:
CONTACT NAME: CELL:
CELL:
ARE SUPPLIES REQUIRED? YES NOIf yes, Supply Order Form must be completed and sent.
• Rural orders are delivered 48 hours prior to clinic, including weekends• Winnipeg orders are delivered day of the clinic (unless otherwise specified above)• Vaccines will only be released to the contact name(s) provided• Contacts must be reachable at phone numbers provided• Drivers will call 30 minutes prior to delivery and upon arrival
VACCINE ORDERS MUST BE SUBMITTED AT LEAST THREE BUSINESS DAYS PRIOR TO CLINIC DATE OR SOONER
DOSES REQUIRED
IMPORTANT INFORMATION
HOLDING POINTNUMBER:
POSTALCODE:
ALTERNATECONTACT NAME:
DIRECTPHONE NUMBER:
WEEKEND HOURSOF AVAILABILITY:
Save form in PDF format and email to both:
[email protected]@gov.mb.ca
COVID VACCINE ORDER FORMMaterials Distribution Agency
7-1715 St. James Street, Winnipeg, MB R3H 1H3Ph: 204-945-3000
VACCINE TYPE:
*Note: Pfizer vaccine is sent with corresponding amount of diluent
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