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|[pic] |Ministry of Health |Ontario Government |Non-Reusable Vaccine |
| |and Long-Term Care |Pharmaceutical and |(spoiled or expired) |
| | |Medical Supply Service |Return Record |
| | |99 Adesso Drive |Toronto Clients |
| | |Concord ON L4K 3C7 | |
| | |Tel. (416) 327-0837 | |
| | |Fax (416) 327-0818 | |
|Contact the Ontario Government Pharmaceutical and Medical Supply Service for a Return Authorization Number. |
|Attach completed form and/or non-reusable vaccine sticker to outside of package. |
|Give to OGPMSS driver when next order is delivered. |
|Client name |Client number |Return authorization no. |
| | | |
|Returned by |Telephone no. |Date of return (yyyy-mm-dd) |
| | | |
|Code name |Description |Lot no. |Cat. no. |No. of Pkg. |*Reason |
| | | | | |for return |
|ADACEL® |Tetanus and Diphtheria Toxoids Adsorbed combined with Component Pertussis Vaccine | |6571-2203-0 | | |
| |(5 x 0.5 mL) | | | | |
|BID (Mantoux) |Tuberculin Purified Protein Derivative 5 TU (Mantoux - 1 mL/5 TU 10 tests) | |6506-3311-0 | | |
|DIPLOID |Rabies Human Diploid Vaccine (1 x 1.0 mL) | |6571-3231-0 | | |
|(Rabies) | | | | | |
|RIG (Rabies) |Rabies Immune Globulin (Human - 2.0 mL vial) | |6571-3225-0 | | |
|ELEMENT |Tetanus and Diphtheria Toxoids and Inactivated Poliomyelitis Vaccine Adsorbed (Td | |6571-3249-0 | | |
|(Td Polio) |Polio - 5 x 0.5 mL) | | | | |
|HEP A (Adult) |Hepatitis A Vaccine (adult - 1 dose syringe 1 mL) | |6571- 3257-0 | | |
|HEP A (Paed) |Hepatitis A Vaccine (paediatric - 1 dose syringe 0.5 mL) | |6571- 3256-0 | | |
|HEP B |Hepatitis B Vaccine (adult - 1 mL vial) | |6571-3243-0 | | |
|ADULT | | | | | |
|HEP B |Hepatitis B Vaccine (paediatric - 0.5 mL vial) | |6571-3251-0 | | |
|PAED | | | | | |
|HEP B REN |Hepatitis B Vaccine (renal dialysis - 1 mL vial) | |6571-3324-1 | | |
|(RECOMBIVAX) | | | | | |
|Meningococcal |Meningococcal C Conjugate Vaccine (single dose - 1 x 0.5 mL) | |6571-3344-0 | | |
|C Conjugate | | | | | |
|(Menjugate®) | | | | | |
|Meningococcal |Meningococcal C Conjugate Vaccine (multi dose – 5 x 0.5 mL) | |6571-3344-2 | | |
|C Conjugate | | | | | |
|(Menjugate®) | | | | | |
|MMR |Measles, Mumps and Rubella Virus Vaccine (MMR - 10 x 0.5 mL) | |6571-3230-0 | | |
|OCEAN (IPV) |Inactivated Poliomyelitis Vaccine (IPV - 5 x 0.5 mL) | |6571-3220-0 | | |
|PENTACE |cPDT-Polio Vaccine (Quadracel®) to reconstitute Haemophilus b Conjugate Vaccine | |6571-3348-0 | | |
|(PENTACEL®) |(Act-HIB®) (5 x 0.5 mL) | | | | |
|PNEUMO1 |Pneumococcal Vaccine, Polyvalent (1 x 0.5 mL) | |6571-4010-1 | | |
|PREVNAR® |Pneumococcal Heptavalent Conjugate Vaccine (10 x 0.5 mL prefilled syringes) | |6571-2202-2 | | |
|SOUND (Td) |Tetanus and Diphtheria Toxoids Adsorbed (Td - 5 x 0.5 mL) | |6571-3240-0 | | |
|SPACE |Component Pertussis Vaccine Diphtheria and Tetanus Toxoids Adsorbed combined with | |6571-3343-0 | | |
|(QUADRACEL®) |Inactivated Poliomyelitis Vaccines (cPDT-Polio - 5 x 0.5 mL) | | | | |
|Influenza |Inactivated Influenza (5 mL vial) | |6571-3323-0 | | |
|TALL |Haemophilus b Conjugate Vaccine for the prevention of Haemophilus influenzae type | |6571-3255-0 | | |
|(Act-HIB®) |b disease among infants (5 x 0.5 mL) | | | | |
|Varicella Vaccine |Varicella Virus Vaccine, Live, Attenuated (Varivax III® - 1 x 0.5 mL) | |6571-3305-1 | | |
|(Varivax III®) | | | | | |
|Varicella Vaccine |Varicella Virus Vaccine, Live, Attenuated (VarilrixTM - 10 x 0.5 mL) | |6571-3308-1 | | |
|(VarilrixTM) | | | | | |
|Vaccines not listed |
| | | | | | |
| | | | | | |
|*Return Codes: |
|[XP] Cold chain break – physician office [OG] Outdated Goods [ER] Power outage |
|[UP] Unsuitable for use (e.g. broken) |
| |
3296-64 (06/08) © Queen’s Printer for Ontario, 2006 7530-5536
|[pic] |Ministère de la Santé |Service d’approvisionnement |Fiche de renvoi de vaccin |
| |et des Soins de longue durée |médico-pharmaceutique |non réutilisable |
| | |du gouvernement de l’Ontario |(altéré ou périmé) |
| | |99 Adesso Drive |Clients de Toronto |
| | |Concord (Ontario) L4K 3C7 | |
| | |Tél. (416) 327-0837 | |
| | |Téléc. (416) 327-0818 | |
| | | | |
|S’adresser au Service d'approvisionnement médico-pharmaceutique du gouvernement de l'Ontario (SAMPGO) pour obtenir un numéro d’autorisation de renvoi. |
|Apposer la formule dûment remplie et/ou l’autocollant du vaccin non réutilisable à l’extérieur de l’emballage. |
|Remettre au livreur du SAMPGO au moment de la livraison de la prochaine commande. |
|Nom du client |Numéro de client |No d’autorisation de renvoi |
| | | |
|Renvoyé par |Numéro de téléphone |Date du renvoi (aaaa-mm-jj) |
| | | |
|Nom de code |Description |No de lot |No de cat. |Nbre |*Raison |
| | | | |d’embal. |du renvoi |
|ADACEL® |Anatoxines tétanique et diphtérique adsorbées combinées à un vaccin | |6571-2203-0 | | |
| |anticoquelucheux composé (5 x 0,5 mL) | | | | |
|BID (Mantoux) |Tuberculine dérivée de protéines purifiées 5 TU (Mantoux - 1 mL/5 TU tests de 10)| |6506-3311-0 | | |
|DIPLOID (rage) |Vaccin antirabique sur cellules diploïdes humaines (flacon de 1 mL) | |6571-3231-0 | | |
|RIG (rage) |Immunoglobuline antirabique (humaine - flacon de 2 mL) | |6571-3225-0 | | |
|ELEMENT |Anatoxines tétanique et diphtérique et vaccin antipoliomyélitique inactivé | |6571-3249-0 | | |
|(dT Polio) |adsorbés (dT Polio – 5 x 0,5 mL) | | | | |
|HEP A (adulte) |Vaccin contre l’hépatite A (adulte – seringue dose unique 1 mL) | |6571- 3257-0 | | |
|HEP A (enfant) |Vaccin contre l’hépatite A (enfant – seringue dose unique 0,5 mL) | |6571- 3256-0 | | |
|HEP B |Vaccin contre l’hépatite B (adulte – flacon 1 mL) | |6571-3243-0 | | |
|ADULTE | | | | | |
|HEP B |Vaccin contre l’hépatite B (enfant – flacon 0,5 mL) | |6571-3251-0 | | |
|ENFANT | | | | | |
|HEP B REN |Vaccin contre l’hépatite B (dialyse rénale – flacon 1 mL) | |6571-3324-1 | | |
|(RECOMBIVAX) | | | | | |
|Meningococcal |Vaccin conjugué contre le méningocoque de souche C (dose unique - 1 de 0,5 mL) | |6571-3344-0 | | |
|C Conjugate | | | | | |
|(Menjugate®) | | | | | |
|Meningococcal |Vaccin conjugué contre le méningocoque de souche C (doses multiples - 5 de | |6571-3344-2 | | |
|C Conjugate |0,5 mL) | | | | |
|(Menjugate®) | | | | | |
|MMR |Vaccin antirougeuleux, antiourlien et antirubéoleux (ROR - 10 x 0,5 mL) | |6571-3230-0 | | |
|OCEAN (VPI) |Vaccin antipoliomyélitique inactivé (VPI - 5 x 0,5 mL) | |6571-3220-0 | | |
|PENTACE |Vaccin cCDT-Polio (Quadracel®) pour reconstituer le vaccin conjugué contre | |6571-3348-0 | | |
|(PENTACEL®) |l’Haemophilus b (Act-HIB®) (5 x 0,5 mL) | | | | |
|PNEUMO1 |Vaccin antipneumococcique polyvalent (1 x 0,5 mL) | |6571-4010-1 | | |
|PREVNAR® |Vaccin antipneumococcique conjugué heptavalent (10 seringues préremplies de | |6571-2202-2 | | |
| |0,5 mL) | | | | |
|SOUND (dT) |Anatoxines tétanique et diphtérique adsorbées (dT - 5 x 0,5 mL) | |6571-3240-0 | | |
|SPACE |Vaccin à base de composant Pertussis et diphthérique et tétanique adsorbées | |6571-3343-0 | | |
|(QUADRACEL®) |combiné au vaccin antipoliomyélitique inactivé | | | | |
| |(cCDT-Polio - 5 x 0,5 mL) | | | | |
|Influenza |Vaccin grippal inactivé (flacon de 5 mL) | |6571-3323-0 | | |
|TALL |Vaccin conjugué contre l’Haemophilus b (5 x 0,5 mL) | |6571-3255-0 | | |
|(Act-HIB®) | | | | | |
|Varicella Vaccine |Vaccin à virus vivant atténué contre la varicelle (Varivax III® - 1 x 0,5 mL) | |6571-3305-1 | | |
|(Varivax III®) | | | | | |
|Varicella Vaccine |Vaccin à virus vivant atténué contre la varicelle (VarilrixTM - 10 x 0,5 mL) | |6571-3308-1 | | |
|(VarilrixTM) | | | | | |
|Vaccins non énumérés |
| | | | | | |
| | | | | | |
|* Codes de renvoi : |
|[XP] Rupture dan la chaîne du froid – cabinet médical [OG] Vaccin périmé [ER] Panne d’électricité |
|[UP] Vaccin non utilisable (p. ex. brisé) |
3296-64 (06/08) © Imprimeur de la Reine pour l’Ontario, 2006 7530-5536
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