[ADVENT] SLIT Rx Pad

ADVENT SLIT Rx Pad

Reference the Wyndly Test Result and Interpretation in the Patient's Chart for help selecting allergens to treat.
Clinic Location (the first dose of SLIT will be sent here)
Prescribing Provider
Patient Name

First NameLast Name
Patient MRN
Take a screenshot of the patient's demographic information and upload here. (Please include: full name, email, phone, date of birth)

Cancelof
Take a screenshot of any drug allergies and upload here:

Cancelof
Select common drug allergies if easier:

No known drug allergiesPenicillinLatex
Allergens to treat:

Common Tree MixAlder (tree)Ceder (tree)Grass MixBermuda GrassCommon Weed MixRagweed MixCatDogDust MiteMolds Mix
RX Notes
Reminder: I have prescribed the patient an epinephrine auto injector (33-66lbs rx Epi Pen Junior 0.15mg and >66lbs Rx EpiPen 0.3mg)

Yes, I have.No.
Allowed Refills (recommend 4 to avoid having to redo the Rx frequently)*
Provider signature for Rx

Clear
Should be Empty:

ADVENT SLIT Rx Pad