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1
Online Order Form
Please complete the form below to reserve your flu vaccine. A Nationwide Medical team member will contact you shortly to confirm your order.
 
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Facility Name*
Contact Name:*
Address:
City:
State:*
Zip Code:
Telephone:*
Fax
E-mail*
Please check the vaccine(s) you prefer:

Will you be vaccinating children?
Quantity of vials required:
(10 doses per vial)
vial(s)
Quantity of pre-filled syringes required:
(10 syringes per box)
box(s)
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2
Call Us!
Toll Free: (800) 997-8846
Phone: (818) 997-8848
Fax: (818) 997-8850
 
Complete form and fax it to:
(818) 997-8850
Or scan and email it to:
info@nationwidemedical.net
 
Order
To order Tamiflu, please download and fax the form below:
Order Form (.pdf)
1. Complete and sign the order form
2. Fax completed form to (818) 997-8850
 
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