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Physician Order Form for Treatment Vials |
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FAX: 904-631-242-3290
ImmuneCare, Inc. IMMUNOTHERAPY ORDER FORMThe Source for Strength and Wellness
Allergy Treatment/Maintenance Prescription
Doctor’s Information: (Please Print) Name: Address: ________- City: State: Zip: _______ Phone: Fax:__________________Credit Card:_____________________Exp:____
Patient Information: (Please Print) Name: * Bill Patient (Complete Below)Address: City: State: Zip: Phone: Credit Card:___________________________Exp:_______
Prescription Set Instructions (Graduated Concentrations with color caps) The maximum number of antigens per vial or set is twelve (12). RAST SCORE DESIGNATED TREATMENT SET(S)
Please supply a 4 Vial Treatment Set based upon the information below or the attached RAST test scores of Class 1 & higher unless otherwise specified. A five-fold treatment set will be supplied.
Vial #1 @ RAST-2, Vial #2 @ RAST-1, Vial #3 @ RAST-0, Vial #4 @ RAST+1 SKIN TEST DESIGNATED TREATMENT SET(S)
Please prepare a 4 Vial Treatment Set based on skin test results listed below, a ten-fold treatment set will be supplied
Vial #1 @ 1:100,000w/v, Vial #2 @ 1:10,000w/v, Vial #3 @ 1:1000w/v, Vial #4 @ 1:100w/v
Maintenance Vial – Reorder of Nelco’s Lot # Lot#
Please Supply: 10ml Vial(s) 5ml Vial(s) SPECIAL INSTRUCTIONS:
| Antigens to be included in Treatment Set #1 |
RAST Class or Skin Test (1+,2+,3+,4+) |
RAST Count(If Applicable) |
Antigens to be included in Treatment Set #2 |
RAST Class or Skin Test (1+,2+,3+,4+) |
RAST Count
(If Applicable) |
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FEDERAL LAW PROHIBITS DISPENSING PRESCRIPTIONS WITHOUT A PHYSICIANS SIGNATURE
RX *Upon Receipt of Patient Payment Nelco will prepare Rx. Following completion of the 14 Day FDA required sterility, the Rx is shipped to Doctor’s office.Physicians Signature: (This form MUST be signed by physician)
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Product Documentation and Instructions 