  |
Printable Order Form |
Print this form, fill out and fax toll-free to 1-877-337-1935 |
ORDER to WESTERN ALLERGY SERVICES, 525 Fort St. - 2nd Floor, Victoria, BC V8W 1E8 fax 1-877-337-1935
| [ ] New Serum Order | [ ] Reorder |
| Patient: | Lot # Vial # |
| Ship to:
|
Bill to:
|
| Patient Date of Birth: | Patient Phone #: |
| Doctor: | Doctor's Phone #: |
| Allergens | Quantity (mL or % - optional) | Proportion (optional) |
| Type: [ ] Aqueous [ ] AP [ ] Other |
Patient is: [ ] Mildly Sensitive [ ] Moderately Sensitive [ ] Very Sensitive |
Treatment Set: [ ] 3-vial [ ] 4 vial [ ] Standard Set |
| [ ] Visa, or [ ] MC, or [ ] Amex | Name on the Card: | |
| Charge Card Number: | Expiry Date: | |
| Other information / Doctor's Notes:
|
||
| Date: | ||