Get Influenza Virus Vaccine Reservation Request Form Vaxserve - Aprx

Filling out the Influenza Virus Vaccine Reservation Request Form VaxServe - Aprx online is a straightforward process. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently to facilitate your vaccine request.

Follow the steps to successfully complete your reservation request form.

1. Click the ‘Get Form’ button to access the reservation request form, which will open it for you to complete.
2. Begin with filling out the customer information section. This includes your customer number, telephone number, customer name, fax number, address, contact name, city/state, email address, and zip code.
3. In the medical director section, enter the medical director's DEA number as well as their name and state license along with the expiration date.
4. Next, move to the vaccine requested section. Specify the type of influenza virus vaccine you are requesting from the options provided. You might also include the NDC number for the specific product.
5. Indicate the number of units and doses you would like to request for your selected vaccine.
6. Check the price associated with each vaccine listed. Note that additional taxes and potential discounts may apply based on the terms provided.
7. Review the terms and conditions associated with the vaccine request before completing the form. Understand that your request is subject to credit review and availability of the vaccine.
8. Once all sections are completed and reviewed, print and sign the form. Ensure you include the date and your printed name.
9. Finally, send the completed form via fax to the number provided. Make sure to keep a copy for your records.

Complete your influenza virus vaccine reservation request form online today.