Augusta Aiken ENT & Allergy
Allergy Vial Order
Patient Information required
First Name
Last Name
Date of Birth
/
/
Best Contact Number
ext
Your Name (if different from the patient)
Allergy Vial(s)
Amount of last dosage required if applicable
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
How often taken
Twice/wk
Weekly
10 Days
14 Days
3 Weeks
Monthly
Candida Vial
Amount of last dosage required if applicable
0.05
0.1
0.15
0.2
0.25
How often taken
Twice/wk
Weekly
10 Days
14 Days
3 Weeks
Monthly
Sublingual Vial(s)
Amount of last dosage required if applicable
1
2
3
4
5
Epi-Pen expiration date required if applicable
/
/
Mail or Pickup?
Mail
Pickup
Preferred office?
Evans
Augusta
Aiken
Statesboro
Grovetown
Has insurance changed?
Yes
No
Pregnant?
Yes
No
Need syringes?
Yes
No
Any problems?
Preferred Pharmacy
List any blood pressure medications
Please allow up to three weeks to mix