Additional Information

Last updated June 27, 2024
Created December 11, 2021
Format application/pdf
Form Number
Form File Identifier 014-4871-64E
Name English - 014-4871-64e - User Agreement for Pharmacies with a Licensed Injection-Trained Pharmacist Requesting Publicly Funded Influenza Vaccines for the 2024/2025 Universal Influenza Immunization Program (UIIP)
Form File Status Available
Language English
Functionality Fill, Print, and Submit
Form File Content Type Form
Edition Date 2024-05