VFC Vaccine Preference Change Form

Please see the form below to change your VFC vaccine brand preferences. Your preferences will remain in effect for the current year. If you wish to change these preferences you must have the approval of your practice’s Responsible Medical Provider. By completing this form you are acknowledging and confirming that you have been delegated to make these changes on behalf of your Responsible Medical Provider.

NOTE: The vaccines that you select will supersede any vaccine brand selections currently on file.

The VFC Program will attempt to honor all vaccine requests, however the VFC Program reserves the right to ship vaccines based on VFC Program need or vaccine supply.

Please review the Suggested Immunization Schedule Using Combination Vaccines.

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Vaccine Preference Change Form

Date*
MM slash DD slash YYYY
VFC PIN*
Name of Responsible Medical Provider*
Responsible Medical Provider's Email Address*
Practice Name*
Phone number*
Fax Number*
Completed By:*
Email*
Instructions for Completion:
Please use this form to update your vaccine brand preferences. Your preferences will remain in effect for 2022. If you wish to change these preferences you must have the approval of your practice’s Responsible Medical Provider. By completing this form you are acknowledging and confirming that you are or have been delegated to make these changes on behalf of your Responsible Medical Provider.
Consent*
I am making changes to my offices vaccine brand preferences with the approval of the Responsible Medical Provider.
Vaccine Brand Preferences
NOTE: The vaccines that you select will supersede any vaccine brand selections currently on file. The VFC Program will attempt to honor all vaccine requests, however the VFC Program reserves the right to ship vaccines based on VFC Program need or vaccine supply. MMR, Polio, Varicella, HPV, and PCV13 are produced by a single manufacturer. Please review the Suggested Immunization Schedule Using Combination Vaccines at the top of this page before completing this section.
DTaP*
Note: Select “Not Applicable” if you are an OB/GYN or only serve adolescent patients.
Combination DTaP*
Note: Providers selecting Pediarix or Pentacel are expected to administer the ACIP recommended number of doses. Pediarix and Vaxelis will be sent in quantities for all 3 recommended doses. Pentacel will be sent in quantities for all 4 recommended doses. Select “Not Applicable” if you are an OB/GYN or only serve adolescent patients.
DTaP-Polio*
Note: DTaP-Polio is an optional use vaccine. Select “Not Applicable” if you do not want to use DTaP-Polio in your office.
MMRV*
Note: ProQuad is an optional use vaccine. Select “ProQuad” if you want to use ProQuad for children 1 year of age and older. Select “ProQuad1Dose” if you only want to use ProQuad for patients 4 years of age and older. Select “Not Applicable” if you do not want to use ProQuad in your office.
HIB*
Note: Select “Not Applicable” if you are an OB/GYN or only serve adolescent patients.
Hepatitis B*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Hepatitis B.
Tdap*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Tdap. Note: Tdap will be required for 7th-12th graders.
Hepatitis A*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Hepatitis A.
Meningococcal*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer MCV4. Note: Meningococcal B Vaccine (Bexsero and Trumenba) are special order vaccines through ImmuNet. Note: MCV4 will be required for 7th-12th graders starting Sept. 2020.
Rotavirus*
Note: Select “Not Applicable” if you are an OB/GYN or only serve adolescent patients.
MMR*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer MMR.
PCV*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Prevnar.
HPV*
Note: Select “Not Applicable” if your practice does not serve adolescent patients.
Polio*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Polio.
Varicella*
Note: Select “Not Applicable” if you are an OB/GYN that does not administer Varicella.
COVID-19 Pediatric*
COVID-19 Adolescent*

Maryland Vaccines for Children Program

Vaccine Preference Change Form

Instructions for Completion:

Vaccine Brand Preferences

VFC Contact Center

Suggested IMM

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