2014-2015 INFLUENZA VACCINE PRE-BOOKING

Flu+
Vaccine Program
2014-2015
INFLUENZA VACCINE PRE-BOOKING ORDER FORM
Customer Number _________________________________
Company Name ___________________________________
E-mail Address ___________________________________
Item #
Description
F a x N u m b e r _____________________________
Phone Number ___________________________
Contact Name _____________________________
Manufacturer #
Age Indication
Fluvirin® (Novartis)
111214
111314
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Price
QTY
Prices include $7.50 excise tax
5ml Multi-Dose Vial, 10 dose/vial
Prefilled Syringe 10 pack(No Needles)
66521-0117-10
Indicated for persons 4 years of age & older
66521-0117-02
Indicated for persons 4 years of age & older
$94.45*
$108.50*
10% returnable (10 vial/box minimum)
Product must be unused and in its original container and returned between January 16, 2015 - February 13, 2015.
Returns will be in the form of a credit towards future purchases.
Customer incurs all freight charges
VOLUME PURCHASE DISCOUNTS AVAILABLE, CONTACT YOUR SALES REP FOR DETAILS*
Fluzone® (Sanofi)
Prices include $7.50 excise tax
222214
5ml Multi-Dose Vial, 10 dose/vial
49281-394-15
Indicated for persons 6 months of age & older
$107.75*
222414
0.5ml 10pk Prefilled Syringes
(No Preservative/No Needles)
49281-014-50
Indicated for persons 36 months of age & older
$119.95*
222614
FLUZONE HIGH DOSE
0.5ml Prefilled Syringe 10 pack
(No Preservative/No Needles)
49231-395-65
Indicated for persons 65 years &older
$344.40*
222714
FLUZONE INTRADERMAL
0.1ml Microinjection Syringes 10 pack
(No Preservative)
49281-709-55
Indicated for persons 18 - 64 years of age
$178.85*
222814
FLUZONE QUADRIVALENT PED
0.25ml Prefilled Syringe 10 pack
(No Preservative/No Needles)
49281-514-25
Indicated for persons 6 - 35 months of age
$231.05*
222914
FLUZONE QUADRIVALENT PFS
0.5mI Prefilled Syringe 10 pack
(No Preservative/No Needles)
49281-414-50
Indicated for persons 36 months of age & older
$199.95*
222014
FLUZONE QUADRIVALENT MDV
5ml Multi-Dose Vial, 10 dose/vial
49281-621-15
Indicated for persons 36 months of age & older
$184.40*
222114
FLUZONE QUADRIVALENT SDV
0.5mI Single-Dose Vial, 10 pack
49281-414-10
Indicated for persons 36 months of age & older
$203.30*
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



20% returnable (10 vial/box minimum)
Product must be unused and in its original container and returned between January 16, 2015 - February 13, 2015.
Returns will be in the form of a credit towards future purchases.
Customer incurs all freight charges
VOLUME PURCHASE DISCOUNTS AVAILABLE, CONTACT YOUR SALES REP FOR MORE DETAILS*
Authorized by ________________________________ P.O. #_______________
Date _____________
Printed Name
_______________________ Company
____________________________
Signature

 All signed flu agreements must be received by March 21, 2014
 The flu agreement guarantees price and prorated delivery schedule.
Notice: All orders are considered confirmed orders and cannot be cancelled.
All shipments are contingent upon availability of the products. Lynn Medical will not be held liable for any delays or failures to fill orders
(even if acceptance of order and shipment of the products has been confirmed). Pricing and availability on all flu vaccine presentations are subject to change.
Call Customer Service at 248-560-4500 for more details
[email protected]
Lynn Medical • 50120 Pontiac Trial • Wixom, MI 48393
1-888-596-6633
Fax: 248-560-0500

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