2 Convenient Toll-Free Service - Allergy Laboratories, Inc.

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Allergy Laboratories, Inc. • www.allergylabs.com ALLergen IMMunotherAPy PresCrIPtIon serVICe treAtMent sets MAde ACCordIng to your PresCrIPtIon prescription service is available to those practices that prefer assistance with compounding treatment sets and maintenance refills. Each prescription is made based on the formula prescribed and to cGMP specifications within a Class 100 (ISO 5) environment. Prescriptions are sent directly to the prescriber after release from a 14 day quarantine that follows sterility testing of every serum vial. 3 gooD reAsons to orDer your prescriptions froM Allergy lAborAtories 1. sAfety, sterility & AccurAcy • cGMP and USP 797 compliant. • Qualified and annually certified clean room technicians wear sterile gowns, hoods, gloves, shoe covers and face masks. • Environmental monitoring throughout the compounding process. • Aseptic manufacturing facility with HEPA filtered air and laminar flow individual workstations. • Every vial is tested for sterility • Department supervised by staff Pharmacist, DPh. 2. econoMy & efficiency • Frees you and other staff members for other important activities. • Saves valuable storage space and eliminates the need to maintain costly extract inventories. • Is accepted by most third-party payers. • Reduces tedious record keeping. We provide mixture and dilution reports, computerized refill tracking and personalized packaging & labeling. 3. siMplifieD orDer proceDure • FAX form makes order placements fast and efficient. • Orders acknowledged shortly after receipt and shipped to your office in approximately 21 to 28 days. 14 Convenient Toll-Free Service (800) 654-3971 We provide a 4-vial set of graduated dilutions in 5 ml vials as prescribed, with a maximum of 12 antigens per prescription formula. Our standard dilutions are ten fold; 1:100,000, 1:10,000, 1:1000 and 1:100. Maintenance vials (refills) are either 5ml or 10ml. Please allow at least 3 weeks for delivery. Our Customer Service personnel and Staff Pharmacist are available for technical assistance.
Allergy Laboratories, Inc. Established 1929 PRESCRIPTION for IMMUNOTHERAPY Fax Rx Order Form to 800-811-3389 Customer Service 800-654-3971 Prescriber Account Name: _______________________________ Account No: ___________________ Prescriber name (printed): ____________________________ Ship to: (no patient-direct shipments) Contact: __________________________________________ ________________________________________ Fax or e-mail (for confirmations): _____________________ ________________________________________ _________________________________________________ ________________________________________ Patient DOB: ______________________ First _______________ Last______________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Treatment Set (for new patients) Initial 4-vial Treatment Set(s) Vial A - 1:100,000 Vial B - 1:10,000 Vial C - 1:1,000 Vial D - 1:100 Maintenance Vial Refill(s) Vial D (1:100) 5mL will be prepared unless otherwise specified. List RX#s and vial sizes below: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Payment Information PO# __________________ Credit card number _______________________________ Name on card: _______________________________ Exp. date __________________ Special instructions List allergens using full catalog name for each new treatment set. It is not necessary to list allergens for refills unless the formula is being modified. No more than 12 allergens will be compounded into one formula. Allergens will be measured as equal parts unless otherwise specified. You may provide an optional serum name for the set (“Grasses”, “Pollens”, etc.). Allow at least 21 days for delivery. This includes a 14-day FDA mandated sterility test period. Treatment set (list allergens here) Treatment set (list allergens here) Serum name (opt): Serum name (opt): 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 Ordering Physicians Signature _______________________________________ Date _______________ Allergy Laboratories, Inc. Form: Rx Order Single Page P.O. Box 348, Oklahoma City, OK 73101-0348 Rev 4 2011 Customer Service 800-654-3971 Fax 800-811-3389 Convenient Toll-Free Service (800) 654-3971 15
Page 1 and 2: Established 1929 2012
Page 3 and 4: tAbLe of Contents Allergenic extrAc
Page 5 and 6: grAss pollens (continueD) 105 SUDAN
Page 7 and 8: fooDs (continueD) 437 PEPPER, GREEN
Page 9 and 10: Allergy Laboratories, Inc. • www.
Page 11 and 12: Vial size reference chart Actual si
Page 13: AchMAn ViAl trAys Dimensions 14”

2 Convenient Toll-Free Service - Allergy Laboratories, Inc.

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