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SCIT ORDER FORM
VENOM ORDER FORM
SLIT ORDER FORM
CUSTOM ORDER FORM

*Western Allergy Services requires a form to be filled out for all named patient vaccine and maintenance (renewal) orders. The ordering physician MUST select the allergens to be used in the named patient vaccine. Orders cannot be processed without a physician’s signature. For reorders with no changes, fill out only the first page, add physician signature. Our compounding lab can customize any order. * Please save in PDF file format for office use. 

SUBCUTANEOUS (SCIT) ORDER TRANSPARENCY: Our unique order form enables you to clearly select the amount of bulk antigen used in the compounding. There are 2 choices depending on the sensitivity of the patient. Standard dosage can be selected and is the volume of bulk extract at the indicated strength to provide a full therapeutic dose based on the North American practice parameters. There is a second option of a half dose for SENSITIVE patients. There is also the option of a custom strength.

  • PLEASE LIMIT TO 6 ANTIGENS PER SET (MIXES COUNT AS 1).

  • PLEASE NOTE THAT IF USING MIXES YOU DO NOT ALWAYS NEED THE INDIVIDUAL ANTIGENS AS WELL.

  • PRESCRIPTION WILL ARRIVE WITH SUGGESTED DOSAGE AND FILL RECEIPT INDICATING ALL ALLERGENS AND STRENGTHS

  • PLEASE IDENTIFY SET #1 or #2 ON REACTION CHART

  • TO COMPLETE THE FORM ONLINE, SAVE AND FILL IT OUT USING A PDF VIEWER

  • MOULDS CANNOT BE MIXED WITH POLLENS

SUBLINGUAL (SLIT) ORDER TRANSPARENCY: Our SLIT orders are compounded at a dilution of total concentrate (Divided by the total allergens used) The volumes of the extract are indicated on the form and your prescription will arrive with a fill receipt indicating again the exact volumes and strengths of allergens in the vial. We offer either a custom compound form or a standardized form based on North American practice parameters.

 

  • PLEASE LIMIT TO 4 ANTIGENS PER SET (MIXES COUNT AS 1).

  • PLEASE NOTE THAT IF USING MIXES YOU DO NOT ALWAYS NEED THE INDIVIDUAL ANTIGENS AS WELL.

  • PRESCRIPTION WILL ARRIVE WITH SUGGESTED DOSAGE AND FILL RECEIPT INDICATING ALL ALLERGENS AND STRENGTHS

  • PLEASE IDENTIFY SET #1 or #2 ON REACTION CHART

  • PLEASE FILL OUT THE FORM ONLINE BY SAVING IT AS A PDF AND OPENING IT WITH A PDF VIEWER

  • MOULDS CANNOT BE MIXED WITH POLLENS