Allergy Refill Form
Patient name
*
Patient DOB
*
-
Month
-
Day
Year
Patient phone number
*
Patient email
*
example@example.com
Date of last available dose
*
-
Month
-
Day
Year
Refill type
*
Traditional Allergy Shots
Sublingual Allergy Drops
Delivery option
*
Mail
Pick Up
Location for pick up
*
Please Select
Anna
Frisco
McKinney
Plano
Prosper
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional supplies requested for mailing
Needles ($5 per box)
Please Select
Needles x 1 box
Needles x 2 box
Needle Clips ($10)
Please Select
Needle Clips x 1
Needle Clips x 2
*
I agree to the $15 mailing fee and any supply options selected above
Payment option
*
Run card on file
Will call to pay
Please verify that you are human
*
Submit
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