Vial Order

"*" indicates required fields

Account #*

THIS INFORMATION IS ON YOUR VIAL OR YOUR STATEMENT.

Patient's First Name*

Patient's Last Name*

Date of Birth

Email*

Last Office Visit Location:

State*

AR Office:

IL Office:

IN Office:

KY Office:

MO Office:

OH Office

PA Office:

TN Office:*

Which Vials are you ordering today?

Vial A & B

Vial A

Vial B

Single Vial

Expiration Date of Vial

Color of Current Vial Top*

Color of Current Vial Top #2

Frequency*

Last Injection Date*

Last Dose Amount*

Reaction*

Yes

Explain Reaction

Submit a Log Sheet*

Drop files here or

Max. file size: 1 GB.

Why is Uploading a Log Required Before Submitting a Vial Order? To ensure the safety and effectiveness of your treatment, it is mandatory to upload a completed log before submitting a vial order. This log helps your provider verify: Your Progress: It confirms that you are following your prescribed treatment plan and that your current dosage is accurate. Allergy Management: It ensures there are no adverse reactions or issues that need to be addressed before proceeding with your next vial. Safety Compliance: It guarantees compliance with clinical guidelines for immunotherapy, reducing the risk of errors. By uploading your log, you are helping us provide you with the best care possible. Thank you for your cooperation.

Ship Vial To

NOTICE: Beginning April 2021, all vials that are shipped will incur a $5.00 Shipping and Handling charge. Vials may be picked up at any FAA location at no cost.

Shipping Options*

Mail Out

Pick Up at FAA Office

Office Location:*

Mail vials to [Name]*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Include extension if necessary

Comments

Name

This field is for validation purposes and should be left unchanged.