1. Immunization Program Resource Guide Request Form 4.0

Patient Education Resources for Immunizations are available to all provider offices in Vermont. To order, you will need your 5-digit Immunization Program Provider Identification Number (PIN).
If you do not have a PIN, please contact the Immunization Program at (802) 863-7638 or by e-mail at immunizationprogram@state.vt.us

* 1. Please enter the following information so we can mail your patient materials to you.

* 2. PIN #

* 3. Please enter your fax number:

* 4. Date of Request:


* 5. Vaccine Issues

* 6. Pregnancy/Infants

* 7. Adolescents

* 8. Adults

* 9. Specific Vaccine Information

* 10. Any questions? Please call the Immunization Program at 1-800-464-4343 X7638. Any suggestions or feedback you'd like to give to the Program? Please use the text box below. Thanks very much!