Secure Form

Facility Name:

Street Address:

City, State, Zip code:

Please indicate how much Flu Vaccine you would like ordered by vials/boxes.
Flu Vaccine is a non-returnable product.

The pricing list is based on pre-booking by May 31, 2022.
All orders are final and cannot be canceled after May 31, 2022.

ORDERS PLACED AFTER THE DUE DATE CANNOT BE GUARANTEED.

Quantity of Vials Ordered	PRODUCT	Doses Ordered	PRICE	TOTAL
	Afluria ^R Quadrivalent Multi-Dose Vial 5ml (10 dose per vial)		$ 175.00 /vial	$
	Afluria ^R Quadrivalent Prefilled Syringes 5ml (10 dose per box)		$ 180.00 /box	$
	Fluad ^R 65+ Prefilled Syringes 5ml (10 dose per box)		$ 550.00 /box	$
	Flucelvax ^R (Cell Based) Prefilled Syringes 5ml (10 dose per box)		$ 230.00 /box	$
			GRAND TOTAL	$

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