Allergy Extract Reorder Form
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Please Indicate One of the Following

Option 1 - One Vial Only

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Option 2 - Two Vial Set

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Option 3 - Three Vial Set

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Option 4 - Seasonal Only

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Option 5 - Perennial Only

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Option 6 - Epidermoid Only

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Please allow 2 weeks for delivery of extract. Please bring a copy of your injection records and insurance card with you to your follow-up visits. Thank you.

Allergy & Asthma Clinic of Macon

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(478) 743-9376

(478) 743-4670

2076 Ingleside Ave, Macon, GA 31204, USA

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