Immunotherapy Order Request

Immunotherapy Order Request
Please note:

This Immunotherapy Order Request form is intended only for allergen immunotherapy products supplied by Gamma, Ferrer or Immunotek. Biologics and other injectable therapies (such as Xolair or Xembify) must be requested via the Script Request section on www.compass.clinic .
Patient Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Contact Name (if order made on another's behalf)

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Is this order initial or ongoing?
Where do you want your order delivered?
Who is your GP?
GP Clinic's name
What is the address for your GP Clinic?

Street Address

Street Address Line 2

SuburbState

Post Code
Would you like to order double supply? (Alxoid, Clustek, ClustekMAX, Alutek and Oraltek orders only)
Clinical Notes / Special Instructions
*Optional
Once our reception team has received your order request,

they will contact you to arrange payment within 48 hours

Current estimated delivery timeframes are:
- Gamma: approximately 6-8 weeks
- Inmunotek: approximately 14–16 weeks
- Ferrer: approximately 18 weeks
Please email any concerns to allergen.orders@compass.clinic
Should be Empty: