|
Antigen Number
|
tarix | 30.04.2018 | ölçüsü | 30,27 Kb. | | #40476 |
|
Patient Name:
Patient Number:
Birth Date:
Telephone:
Prescribing Physician:
Address:
Telephone:
Fax:
Maintenance Concentrate Prescription Form
Allergen Extract Name:
|
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
Dostları ilə paylaş: |
|
|