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By filling out and submitting this form, your request for information will be e-mailed to the Pennsylvania Immunization Education Program. Please note that fields in red are required. Depending on your selection in Section 2, you will also be required to fill out the appropriate corresponding section below. Thank you.

SECTION 1 Personal Information
Name:
Degree:
MD
DO
CRNP
PA
RN
Other:
Practice Name:
Practice Type: Pediatrics
Family Practice
Mixed
Other:
Address 1:
Address 2:
City:
State:
Zip:
E-mail:
A copy will be e-mailed to the address provided
Phone:
Must be in 123-456-7890 format.
Fax:
Must be in 123-456-7890 format.

SECTION 2 I would like to:
Your Request:

(Go to Section 3)
(Go to Section 4)
(Go to Section 5)
(Go to Section 6)


SECTION 3 Schedule an On-Site IEP Presentation
VFC Provider?:



If yes, VFC Pin #

We would like to schedule an Immunization Education Program for our staff. Here are three potential dates for the 1 1/2 hour presentation.
Date Time of Day
//
//
//
Use format: MM/DD/YYYY Example: 9:30 AM
 

SECTION 4 Become a Presenter
NOTE: You will be asked to provide a current CV and to sign an annual disclosure form to meet CME guidelines.
Provider Type:
Pediatrician
Family Physician
Nurse Practitioner
Physician’s Assistant
Nurse
Office Manager
Access to Slide Projector:


Access to LCD Panel:
Access to a Laptop Computer:
I am willing to travel to the following counties:
I am generally available to do presentations at the following days/times:
 

SECTION 5 Order Materials
Immunizations Work Poster:
Quantity Language
English Spanish
IMMUNIZE Poster:
Quantity Language
English Spanish
Ask At Every Visit... Poster:
Quantity Language
English Spanish
PA Immunization Card:
Quantity Language
English Spanish
Immunization Dose Counter:
Quantity  
 
Shipping Address:


(Enter Below)

Name:
Practice Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Must be in 123-456-7890 format.
Fax:
Must be in 123-456-7890 format.
 

SECTION 6 Request Other Information
Choose One: I would like more information on the Immunization Education Program.
  I have a question about
  Please send me information about the following immunization issue:
 
   
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