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IMMUNIZATIONS OFFERED
BY THE WILKES UNIVERSITY HEALTH SERVICES OFFICE
Below please find a list of the immunizations offered by the University Health
Services Office. Please print this page, check the appropriate box and return with your payment to the address below. Diphtheria Tetanus Toxoid: _____ $20.00
Mantoux Test (Tuberculosis): _____ $10.00 Diphtheria Tetanus Toxoid, Pertusis _____ $40.00 Menactra™A/C/Y/W-135
(Meningococcal Vaccine): _____$100.00
Hepatitis B vaccine three dose: _____$100.00 series (3 injections)
for students up to the $ 35.00 per injection
age of 19 who will complete all three shots prior to their 20th birthday for all others _____$150.00 series (3 injections)
(over 20 years old) $ 50.00 per injection
All immunizations must be paid for prior to time of injection
Make check payable to: Health Services Wilkes University
Send payment to: 84 West South Street, Wilkes-Barre, PA 18766
Tel: 570 408-4730 Fax: 570 408-7873
Student's Name: ___________________________Date of Birth:____________________
Social Security #:___________________________Phone #:________________________
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