Vaccine Return Form

Please complete this Vaccine Return Form for any vaccine eligible for return by the Providers. The clinic will be financially responsible for annual vaccine lost/wastage greater than 5%. Amounts entered on this form must match what is entered into MIIX. Amounts entered on this form must match amount of vaccine placed in shipping box for return to McKesson.


Only 1 Funding Source is allowed per entry. If you needing to return VFC and CHIP vaccines, then you must fill out 2 separate forms.

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Phone

Return Label will be sent to this email address.

For all the returns you are reporting today.

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Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

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Funding Source*

Only 1 Funding Source allowed per entry

Vaccine Return Reason*
More Vaccine to Return?*
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Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

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Vaccine 2 – Return Reason*
I have more Vaccine to Return?*
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Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

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Vaccine 3– Return Reason*
I have another vaccine to return*
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Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

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Vaccine 4 – Return Reason*
Another vaccine to return?*
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Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

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Vaccine 5 – Return Reason*
Additional Vaccine to Return?*
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