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@ahs.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:
MM DD YYYY
Month/Day/Year
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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!
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