2 Convenient Toll-Free Service - Allergy Laboratories, Inc.
2 Convenient Toll-Free Service - Allergy Laboratories, Inc.
2 Convenient Toll-Free Service - Allergy Laboratories, Inc.
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<strong>Allergy</strong> <strong>Laboratories</strong>, <strong>Inc</strong>. Established 1929<br />
PRESCRIPTION for IMMUNOTHERAPY<br />
Fax Rx Order Form to 800-811-3389<br />
Customer <strong>Service</strong> 800-654-3971<br />
Prescriber Account Name: _______________________________ Account No: ___________________<br />
Prescriber name (printed): ____________________________ Ship to: (no patient-direct shipments)<br />
Contact: __________________________________________ ________________________________________<br />
Fax or e-mail (for confirmations): _____________________ ________________________________________<br />
_________________________________________________ ________________________________________<br />
Patient DOB: ______________________<br />
First _______________ Last______________________<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
_________________________________________________<br />
Treatment Set<br />
(for new patients)<br />
Initial 4-vial Treatment Set(s)<br />
Vial A - 1:100,000<br />
Vial B - 1:10,000<br />
Vial C - 1:1,000<br />
Vial D - 1:100<br />
Maintenance Vial Refill(s)<br />
Vial D (1:100) 5mL will be prepared unless otherwise specified.<br />
List RX#s and vial sizes below:<br />
_________________________________________<br />
_________________________________________<br />
_________________________________________<br />
_________________________________________<br />
_________________________________________<br />
Payment Information PO# __________________<br />
Credit card number _______________________________<br />
Name on card: _______________________________<br />
Exp. date __________________<br />
Special instructions<br />
List allergens using full catalog name for each new treatment set. It is not necessary to list allergens for refills unless<br />
the formula is being modified. No more than 12 allergens will be compounded into one formula. Allergens will be<br />
measured as equal parts unless otherwise specified. You may provide an optional serum name for the set (“Grasses”,<br />
“Pollens”, etc.). Allow at least 21 days for delivery. This includes a 14-day FDA mandated sterility test period.<br />
Treatment set (list allergens here) Treatment set (list allergens here)<br />
Serum name (opt): Serum name (opt):<br />
1 1<br />
2 2<br />
3 3<br />
4 4<br />
5 5<br />
6 6<br />
7 7<br />
8 8<br />
9 9<br />
10 10<br />
11 11<br />
12 12<br />
Ordering Physicians Signature _______________________________________ Date _______________<br />
<strong>Allergy</strong> <strong>Laboratories</strong>, <strong>Inc</strong>. Form: Rx Order Single Page<br />
P.O. Box 348, Oklahoma City, OK 73101-0348 Rev 4 2011<br />
Customer <strong>Service</strong> 800-654-3971 Fax 800-811-3389<br />
<strong>Convenient</strong> <strong>Toll</strong>-<strong>Free</strong> <strong>Service</strong> (800) 654-3971 15