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Forms, Referrals and Ordering
Vaccines and immunization
- 0-18 Report of Immunization form (PDF, 1 page, 102 KB)
- Report of Adverse Event Following Immunization (AEFI)
- Statement of Medical Exemption – Immunization of School Pupils Act
- Statement of Medical Exemption – Childcare and Early Years Act
- Vaccine Order Form (PDF, 1 page, 243 KB)
- Vaccine Return Form (PDF, 1 page, 439 KB)
- Vaccine Temperature Log Book (PDF, 26 pages, 3 MB)
- Thermometer Order Form (PDF, 1 page, 132 KB)
- COVID-19 Vaccine Order Form (Updated April 2024; PDF, 1 page, 56 KB)
- 2024-2025 Influenza COVID-19 Vaccine Order Form (PDF, 1 page)
- RSV and RSV Prophylaxis Order Form 2024-25 (PDF, 1 page)
Infectious diseases
- Animal Exposure Report (PDF, 1 page, 168 KB)
- Rabies Vaccine & Immune Globulin: Patient Vaccination Schedule (PDF, 1 page, 70KB)
- Positive TB Skin Test (TST) IGRA Reporting Form (PDF, 1 page, 201 KB)
- HCV Questionnaire for HCP (Fillable PDF, 4 pages, 373 KB)
- Hepatitis B Vaccine HBIG Reporting Form for High-Risk Infants (PDF, 1 page, 176 KB)
- Hepatitis B Questionnaire for Physicians (PDF, 4 pages, 181 KB)
Mandatory Blood Testing Act (MBTA)
Fax applications to our secure Reportable Diseases fax line: 1-855-WDG-LINE (1-855-934-5463).
Outbreaks
- Daily Outbreak Line Listing Fax Cover Sheet (PDF, 1 page, 104 KB)
- Enteric Outbreak Line Listing (PDF, 1 page, 140 KB)
- Respiratory Outbreak Line Listing (PDF, 1 page, 827 KB)
- Thermometer Order Form (PDF, 1 page, 132 KB)
- Vaccine Return Form (PDF, 1 page, 439 KB)
Sexually transmitted infections (STIs)
- Chlamydia Treatment Request for Information Fax Sheet (PDF, 1 page, 101 KB)
- Gonorrhea Treatment Request for Information Fax Sheet (PDF, 1 page, 101 KB)
- STI (Sexually Transmitted Infection) Medication Order Form (PDF, 1 page, 91 KB)
- STI (Sexually Transmitted Infection) Medication Log (PDF, 1 page, 76 KB)
Prenatal and parenting
- Prenatal referral form (PDF, 2 pages, 726 KB)
Oral Health
- Dental Outreach Referral Form (PDF, 3 pages, 245 KB)