"*" indicates required fields Account #*THIS INFORMATION IS ON YOUR VIAL OR YOUR STATEMENT.Patient's First Name*Patient's Last Name*Date of Birth MM slash DD slash YYYY Email* Last Office Visit Location:State*CHOOSE STATEARILINKYMOOHPATNAR Office:CHOOSE OFFICEConway, AR (AAAC)Jonesboro, AR (FAA)Little Rock, AR (AAAC)IL Office:CHOOSE OFFICEGurnee, ILLibertyville, ILIN Office:CHOOSE OFFICEAvon, INBloomington, INClarksville, INColumbus, INCorydon, INGreenwood, INJeffersonville, INMadison, INNew Albany, INNoblesville, INScottsburg, INZionsville, INKY Office:CHOOSE OFFICEBardstown, KYBullitt County, KYCampbellsville, KYElizabethtown, KYFrankfort, KYFlorence, KYGeorgetown, KYLa Grange, KYLeitchfield, KYLexington, KY - AndoverLexington, KY - BeaumontLondon, KYLouisville, KY - Main Office (East End)Louisville, KY - Chamberlain CenterLouisville, KY - DowntownLouisville, KY - DupontLouisville, KY - Fern CreekLouisville, KY - Goss AvenueLouisville, KY - ShivelyLouisville, KY - South EndLouisville, KY - St MatthewsLouisville, KY - Landis LakesNewport, KYNicholasville, KYPaducah, KYRadcliff, KYRichmond, KYShelbyville, KYSomerset, KYMO Office:CHOOSE OFFICEColumbia, MOJefferson City, MORolla, MOSedalia, MOWarrensburg, MOOH OfficeCHOOSE OFFICEBeavercreek, OHChillicothe, OHColumbus, OH - East BroadColumbus, OH - WorthingtonDayton, OH - CentervilleDelaware, OHFairfield/Hamilton, OHHilliard, OHHuber Heights, OHGrove City, OHKenwood, OHLancaster, OHMansfield, OHMason, OHMilford, OHNewark, OHOxford, OHSpringboro, OHSpringfield, OHWilmington, OHZanesville, OHPA Office:CHOOSE OFFICEHanover, PAYork, PATN Office:*CHOOSE OFFICEChattanooga, TNCleveland, TNJackson, TNJasper, TNLakeland, TNMemphis, TNWhich Vials are you ordering today? Vial A & B Vial A Vial B Single Vial Expiration Date of Vial MM slash DD slash YYYY Color of Current Vial Top*RedYellowBlueSilverPurpleGreenColor of Current Vial Top #2--RedYellowBlueSilverPurpleGreenFrequency*once per week2-3 times per weekonce every 2 weeksonce every 3 weeksonce every 4 weeksonce every 5 weeksonce every 6 weeksLast Injection Date* MM slash DD slash YYYY Last Dose Amount*Reaction* Yes No Explain ReactionSubmit a Log Sheet* Drop files here or Select files 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 ToNOTICE: 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Include extension if necessaryCommentsPhoneThis field is for validation purposes and should be left unchanged.
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