Out of Province Immunotherapy (Allergy Serum) Request Form

For first-time immunotherapy orders, please contact the clinic directly at 519-821-7546 to place your first order to ensure it is processed properly and all necessary information is recorded.

Please allow up to 3 weeks for the Immunotherapy (Allergy Serum) to be produced and shipped.

Your First Name

Your Last Name

Pet's Name

Secondary Last Name (that your pet may be listed under)

Address Line 1

Address Line 2

City/Town

Province

Postal Code

Phone

(###)

###

####

Secondary Phone Number

Primary Veterinary Information

Primary Veterinary Clinic Name

Phone

(###)

###

####

Address Line 1

Address Line 2

City/Town

Province

Postal Code

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

YYYY

Are you requesting Oral or Injectable Immunotherapy?

Oral

Injectable

Is your pet receiving or been prescribed 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

If your 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 is required at the time of order

I understand

Checkbox

Option 1

Option 2