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 (100)
	Adult (100)
	Childhood (100)
	Childhood 8.5" x 11" (50)
Other Materials	Plastic Sleeves (100)
	"Next Due" Stickers (250 per pad)
	Immunization Guide Book (Redbook) 2008-2009
	Utah School & Early Childhood Program Guidebook for Health Care Providers 2008-2009
	PPV Stickers (500 per roll)
	Vaccinate Before You Graduate Bookmark
	Got Vaxed Bookmark
Exemption Forms	Medical
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"
VIS	Camera Ready Set
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)
	The Utah School Immunization Rule (100)
	Vaccinate Before You Graduate (100)
	Vaccine Safety (50)
Tearpads & Notepads	Resources for Immunizations Tearpad (50)
	Vaccine Administration Record Tearpad (50)
	VFC Information Tearpad (50)
Limited Materials	Rocking Horse Magnets (Limit 100)
	Reload	Enter the Text:
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

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