Antigen Number

Allergen Immunotherapy Extract Prescription Form

Patient Name:

Patient Number:

Birth Date:

Telephone:

Prescribing Physician:

Address:
Telephone:

Fax:





Maintenance Concentrate Prescription Form




Allergen Extract Name:

Bottle Name Abbreviations
Tree: T	Mold: M
Grass: G	Cat: C
Weed: W	Dog: D
Ragweed: R	Cockroach: Cr
Mixture: Mx	Dust Mite: Dm

Dates of subsequent dilutions from maintenance concentration with expiration dates

Vial ________ from Vial ________ on __/__/__ Expiration date:__/__/__

Vial ________ from Vial ________ on __/__/__ Expiration date:__/__/__

Vial ________ from Vial ________ on __/__/__ Expiration date:__/__/__

Vial ________ from Vial ________ on __/__/__ Expiration date:__/__/__

Prepared by: ________________ Date Prepared:__/__/__

Antigen Number	Extract Name Allergen or Diluent (Common name or Genus/species )*	Concentration and Type Manufacturer’s Extract (AU, BAU, W/V, PNU)/ (50% G, Aq, Ly, AP)	Volume of Manufacturer’s Extract to Add	Extract Manufacturer	Lot Number	Expiration Date
1
2
3
4
5
6
7
8
9
10
Diluent
Total Volume

* Components of mixes listed on a separate sheet

Maintenance concentration and subsequent dilutions reported as volume/volume (v/v) dilutions with maintenance concentration=1:1 v/v

x Total volume volumevolume*

Maintenance Concentration

Conc. Of Manufacturer’s Extract

Volume to add =
Specific Instructions: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________

BAU = Bioeqivalent Allergy Unit, AU =Allergy Unit

PNU=Protein Nitrogen Unit

W/V=Weight per Volume Ratio

G= 50 % Glycerinated

Aq=Aqueous, Ly=Lyophilized

AP= Alum precipitated, AcP= Acetone precipitated

Updated 3/7/2010