Antigen Number



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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



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