Immunization Materials
Schools and Childcare Order Form

If you are outside of Contra Costa County, please contact your local county Immunization program.

Instructions

Please use this form to order Immunization Supplies. Please indicate address and contact information. Fax completed Order Form to Connie Ward at 925-313-6036 or fill-up Online Order Form and Submit.

Fax Order Form (PDF)

Online Order Form

School District/School:
Contact Name:
Telephone No:
Street Address:
City & State:
Zip:
E-mail:

Please select the items and indicate the quantity you would like to order.

	Item Description	Quantity
	Blue Cards (California School Immunization Record (PM 286)
	Lavender Window Card Schools (K-12) Immunizations
	Pink Window Card (Childcare) Immunizations
	(English)-Public Health Immunization Clinic Calendar
	(Spanish)-Public Health Immunization Clinic Calendar
	California Immunization Handbook - 2003 (Latest Version)
	Tdap Sticker (To be put on Blue Card)
	Tdap Personal Belief Exemption Form
Notes: (optional)
Enter the numbers:

For further information or assistance contact the Immunization Program at 925-313-6767.