Phone *

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When was the last dose of Immunotherapy administer to your pet? *

MM

DD

YYYY

Are you requesting Oral or Injectable Immunotherapy? *

Oral

Injectable

Is your pet receiving Single Vial or Double Vial Immunotherapy? *

ORAL: Single Vial - Allergens are combined into two vials Double Vial - Allergens are split into two separate mixes due to the high number of positive reactions. The order will include four vials total. INJECTABLE: Single Vial - All allergens are combined into one vial. Double Vial - Allergens are split into two vials due to the pet having a high number of positive allergy reactions

Single Vial

Double Vial

Where would you like to pick up your order? *

Addition charges apply for shipping

Pick up at VADER Clinic (Morriston, Ontario)

Ship to my veterinarian (Additional charges apply)

If your refill request is approved, how would you like to pay? *

For all payment, methods, a receipt of payment will be emailed to your after payment collection

I authorize you to use my credit card on file.

Please call me to collect payment.

Payment for immunotherapy and shipping (if applicable) is required at the time of order *

I understand