Allergy Serum / Immunotherapy Refill Request Form

Please fill out the below form to request an allergy serum/immunotherapy refill. This questionnaire is designed to help us assess the efficacy of our current allergy treatments and to help us determine if any adjustments need to be made before completing your refill request.

Refills of immunotherapy should be requested when you have 1-2 doses of serum remaining in your vial. Orders generally take up to 2 weeks to process and ship.

All fields must be filled out prior to submission.

Owner Name (First/Last)*

Pet Name*

Species*

Dog
Cat
Horse

What is the best phone number and e-mail to contact you?

Phone*

Email*

1. What is the current dosage (volume) and frequency (once weekly, once every other week, etc.) of your pet’s immunotherapy? Please describe.*

2. Have you seen any side effects from the immunotherapy injections? (Ex: hives, swelling, increased scratching, redness, other)*

Yes
No
Unsure

If yes or unsure, please describe any side effects or concerns.

3. How many allergic flares have you noticed in the last 6 months? Select one.*

0
1-3
Greater than 3

If any, please describe the symptoms you notice during these flares including increased licking, chewing, scratching, rubbing, rolling, or scooting.

4. Overall, do you think that immunotherapy has been effective in decreasing allergic symptoms, frequency of flares, or the medications needed to treat your pet’s allergies?*

No, my pet is still experiencing the same allergy symptoms as before immunotherapy
Yes, but my pet’s allergies are not well controlled and he/she flares often requiring treatment
Yes, my pet has had an overall reduction in allergic flares and treatments, but he/she still requires treatment occasionally
Yes, my pet’s allergies are very well controlled with few to no flares or treatments needed

Optional Comments

5. Is your pet currently receiving any of the following medications? If so, please provide the dosage (10mg, 50mg, etc.), frequency (once daily, twice daily, etc.), and duration (1 week, 3 months, etc.) for which they have received each medication.

Immunosuppressant/immunomodulatory:

Atopica, Cyclosporine, Apoquel, Cytopoint

Anti-fungal:

Ketoconazole, Miconazole, Itraconazole

Antihistamine:

Benadryl, Zyrtec, Chlorpheniramine, Hydroxzyzine

Steroid (topical and oral):

Prednisone, Prednisolone, Triamcinolone, Mometasone, Dexamethasone, Temaril-P, GenOne spray, Genesis spray, Mometamax, Posatex, etc.

Other Medications:

Any other medications not listed above that may contain these drugs? (If in doubt, please list it and we can determine if it falls into one of the above categories.)

6. Do you need us to ship your immunotherapy to you?*

Yes
No

Please provide us with your shipping address*

Street Address Address Line 2 City State ZIP Code

Shipping Agreement*

I understand that refrigerated shipping is $35 and that my medication cannot be shipped to P.O. boxes or addresses outside the state of Georgia. Additionally, please be aware that our pharmacy does not ship on Fridays. Packages shipped M-Th typically arrive next-day.*

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