Allergy & Asthma Clinic of Macon

2076 Ingleside Ave., Macon, GA 31204

1-800-648-7761
 
 
To re-order your extract mixture, please provide the following information:
Patient's Name:
Date of Birth :

Date of Last Injection
Record #:
(located on the side of the vial)
 Color of Vial:
Red Gold Blue Green Silver
Dosage of Last Shot: cc
Frequency of Shots:
Reactions Noted
Patient's Results: Excellent Good Fair Poor No Difference
Please indicate the following:
1 Vial Only
Color Vial Ordered:
Red Gold Blue Green Silver
2 Vial Set
Seasonal:
Red Gold Blue Green Silver
Perennial:
Red Gold Blue Green Silver
3 Vial Set
Seasonal:
Red Gold Blue Green Silver
Perennial:
Red Gold Blue Green Silver
Epidermoids:
Red Gold Blue Green Silver
Send Extract To:
PLEASE PROVIDE FULL ADDRESS:
Please allow 2 weeks for delivery of extract.  Please bring a copy of your shot records when you come in for your follow up visits, and your insurance card.  Thank you.

© 2000-2004 Allergy & Asthma Clinic of Macon

Professional Website by InfiniteEmail.com