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)
	Yellow Personal Record (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) 2007	Out of Stock
	School Rule Guide Book for Providers 2007	Out of Stock
	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" NEW
VIS	Camera Ready Set
Brochures	A Guide for Health Care Providers
	About Hepatitis A (50)
	About Hepatitis B (50)
	Got Vaxed Adolescent Brochure (100)
	Older Adults Need Shots (100)
	Planning a Trip (100)
	Preteen Doctor Visit (100) NEW
	Protect Yourself Adult (100)
	Questions & Answers (25)
	Vaccinate Before You Graduate (100)
	Vaccine Safety (50)
	Get the Flu Vaccine (50)
Tearpads & Notepads	Got Vaxed Notepad 3" x 3"
	Resources for Immunizations Tearpad (50)
	Vaccine Administration Record Tearpad (50)
	VFC Information Tearpad (50)
Limited Materials	Fever Scans (Limit 100)
	Rocking Horse Magnets (Limit 100)
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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