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ADVANCE PROTECTION:
PREORDER FLU VACCINES BEFORE FLU SEASON BEGINS.

order form

For better assistance, please fill out the form below and we will contact you as soon as possible.

* is a required field

You may also download and fax completed form to:

Fax: 305-351-3001 | Email: service@novispharma.com

Phone: 305-351-3000 | Toll-free: 1-800-727-6711

download flu order formPREBOOK FLU VACCINES.xls
(click to download MS Excel Form)

 
Account Info
*Name of Facility
Customer Number
*Contact Name
*Title
*Phone
*Email
Fax
Sales Representative ID
New Account
All major credit cards are accepted
 
 
SHIPPING INFORMATION
Department
Shipping Address
City
State
Zip
 
BILLING INFORMATION (if different than shipping)
Attention
Billing address
City
State
Zip
   
 
Required Info
*P. O. #
*Pharmacy License #
*Issuing State
*Expiration Date
 
 
Product Info
  Quantity
Fluvirin (Novartis)
Indicated for persons 4 years of age and older 5ml MDV (10 doses/vial)
 Vials
Fluvirin (Novartis)
Indicated for persons 4 years of age and older Box of 10 0.5ml Syringes
 Boxes
Afluria (CSL)
Indicated for persons 18 years of age and older Box of 10 0.5ml Syringes
 Boxes
Fluzone (Sanofi Pasteur)
Indicated for persons 6 months of age and older
5ml MDV (10doses/vial)
Vials
Fluzone (Sanofi Pasteur)
Indicated for persons 6 - 35 months of age Pediatric Pre-filled Syringe (Box of 10 0.25 ml Syringes)
Boxes
No Brand Preference (Best Value)
Bx/VI
*Includes Excise Taxes
Disclaimer: Products are subject to manufacturer availability.
Customer Signature
Title
Please Note: Unless otherwise specified, Flu Vaccine is Non-Returnable. Any prebook order not cancelled in writing by July 30th will automatically be shipped & billed.
Placing Your Order
Fax completed order form to: 305-351-3001
To order by phone: 800-727-6711
As required by law, a copy of your State Pharmacy License or Physician License must be on file before your order can be shipped. Novis Pharmaceuticals, LLC nor any of it's affiliates will be held liable for delays or product shortages, in no event shall Novis be liable to customer for incidental, special, or consequential damages (including loss profit) from any cause including without limitation, damages resulting unavailability of, defect in, or mis-shipment of products.