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Request Allergy Extract Out
Extract Request Form
Please provide the following information. Upon completion, it will be sent directly to our lab. Allow 10 days for processing.
Today's Date:
MM slash DD slash YYYY
Patient Name:
(Required)
Patient Phone #:
(Required)
Email:
Administrating Location
Name of physician/college:
(Required)
Department:
Attention:
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Days and hours of operation for the facility/office administering injection:
Phone:
(Required)
Fax:
How would you like to receive extract vials?
(Required)
Mail
Pick up at Office
When would you like to pick up your extract vials?
MM slash DD slash YYYY
Pick up location:
Albany
Troy
Clifton Park
Niskayuna
Saratoga
Mail:
to above address
to a different address
If your extract needs to be mailed to an address other than above, please indicate the name and address of where the extract will be sent
Name:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
I agree to and acknowledge the following:
(Required)
I am responsible for verifying the location I have chosen to administer my allergy injections will do so. Extract vials require refrigeration.. During transport they can be stores at room temperature for a maximum of two days. If vials are mishandled by me in transit or the receiving location upon receipt, I am responsible for the cost of replacement.
Credit Card Consent
(Required)
If I request vials to be mailed, they will be sent Priority US Mail and the cost will be paid by me. This includes refill vials ordered on my behalf by administrating location. I understand my credit card information will be kept on file for future use. You will be contacted for your credit card information and provided a cost prior to charging my card and mailing.
(Required)