Allergen Refill Request

AADC ALLERGEN/IMMUNOTHERAPY Refill Request

Simply request your pet's refill of allergen and immunotherapy here. Need shipped? Just let us know! Want to pick up here in our office - we can arrange that for you! If you would rather place your order with someone at our clinic directly, you can call us at 719-358-2636. *Please note that there is no way for us to quote the price on this form because this is a custom medication. If you want to know what the cost will be, please call us by phone and speak with a team member who can look this information up for you.*
Owner Name*

First NameLast Name
Pet's Name*
PLEASE NOTE THAT ALLERGEN REFILLS REQUIRE PRE-PAYMENT AND HAVE LONGER DISPENSE TIMES. PLEASE ALLOW UP TO 30 DAYS FOR ALLERGEN REFILLS PRIOR TO SHIPPING.
Which option do you need refilled?*

allergen INJECTION vial(s)allergen SUBLINGUAL vial(s)
How is pet doing? Any increased itch noted after injections/sublingual therapy? *
What is the pets current dose and frequency?*
Syringes Needed?*

YESNO
Do you want this item shipped to you?*

YesNo
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Primary E-mail *
Please choose the best option for your payment and pickup.*

Pickup at your office - Go ahead and charge my card on file for full payment dueMail to me - Charge my card on file for full payment due (I understand there will be a shipping fee).
We ship primarily through FedEx. If you need another shipping provider, please let us know:
Please verify the last 4 digits of your card on file that you authorize us to use.*
Last 4 digits of card number
Do you want to be notified when ready?*

No needYes, text meYes, email me
Any notes?
Should be Empty:

AADC ALLERGEN/IMMUNOTHERAPY Refill Request