Out of Province Immunotherapy (Allergy Serum) Request Form

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

For first-time orders, processing may take longer due to initial formulation

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

Is this an Initial Order or a Refill?

Initial Order

Refill Order

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