PROPAC REORDER FORM FAX 360-260-7237 OR 1-800-840-2590
Facility Name: _______________________________________ Contact Name: ______________________________________ PLEASE PROVIDE FACILITY WITH GENERIC HEPATITIS B VACCINE, PRE-FILLED SYRINGE. QUANTITY REQUESTED: ___________ THIS PRODUCT SHOULD BE BILLED TO THE FACILITY HOUSE SUPPLY AT THE CONTRACTED RATE.
This product is being order for employee: __________________________________________ (Print name)
This product is being order for employee: __________________________________________ (Print name)
Pharmacy use only:
Tech initials __________________
Date ____/____/____
