• No contract is needed for 2010 season
• No obligation to purchase after pre-booking - Cancel as late as August first 2010
• Why to sign a contract with any vender

I am Pre-Booking

____ Vials of Ten-dose vial of “FLULAVAL” Made by Glaxo (FOR 18 YEARS AND OLDER)

____ Vials of Ten-dose vial of “AFLURIA” Made by CLS (FOR 18 YEARS AND OLDER)

____ Vials of Ten-dose vial of “FLUVIRIN” Made by Sanofi (FOR 4 YEARS AND OLDER)

____ Vials of Ten-dose vial of “FLUZONE” Made by Sanofi  (FOR 6 MONTHS OR OLDER)

____ Doses of Preservative Free single-dose syringe (or vial) of PEDIATRIC FLUZONE  (Box of 10)

____ Doses of Preservative Free single-dose syringe of ADULT FLUZONE (Box of 10)

____ Doses of _______________”FLUMIST” Made by Medimmune (Box of10 Nasal Spray)

Print first and last name of doctor or pharmacist who is pre-booking

___________________________________ ___________________________________

Office Tel: _________________________Inside line # ___________________________

Office Fax # __________________________

Office Email Address______________________________________________

Name of the Email Contact_____________________

*Signature* of purchasing health care professional (doctor/ pharmacist/ nurse practitioner)

 _________________________________________________________ Date ____________________              

Additional Note if any________________________________________________________________________

Please fax the completed order and your business fax cover sheet to

Toll Free Fax: 888-488-6828