City and County of San Francisco
San Francisco Department of Public Health
Communicable Disease Control & Prevention
Communicable Disease Prevention Unit
101 Grove Street, Room 406
San Francisco, CA 94102
Phone: (415) 554-2955
Fax: (415) 554-2579
ww.sfcdcp.org
SFDPH Vaccine Request Form
We are trying to save paper! We prefer that you email this request to Tina.Milton@sfdph.org AND
immunization.dph@sfdph.org with the subject line “Vaccine Request”. If you are unable to email the
request, you may fax it to (415) 554-2579. Thank you!
Please allow at least 4 business days for the IZ Program to fill this order. If you have an urgent need
for this order to be shipped earlier than 4 business days, please complete:
Please have this order ready by (date):_________ because________________________________
_______________________________________________________________________________
Please bring a hard sided cooler, ice packs, bubble wrap, and use your backup digital data logger to
monitor temperatures while transporting vaccine. Please refer to the VFC job aid to learn more about
best practices for transporting refrigerated vaccine: http://www.eziz.org/assets/docs/IMM-983.pdf.
Pick up times vary - the SFDPH Vaccine Inventory Manager will contact you with pick up times when
your vaccine order is ready.
Date:
Health Center:
Name Of Person Requesting Vaccine:
Phone Number:
Vaccine Requested
Number
of Doses
Current inventory
Number of Doses Exp. Date mm/dd/yyyy
Hep A, Adult (Havrix)
Hep B, Adult (Engerix-B)
Hep A-HepB, Adult (Twinrix)
