Account #*THIS INFORMATION IS ON YOUR VIAL OR YOUR STATEMENT. Patient's First Name* Patient's Last Name* Email* Which Vials are you ordering today? Vial A & B Vial A Vial B Single Vial Date of Birth MM slash DD slash YYYY 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 ReactionShip 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Include extension if necessaryCommentsNameThis field is for validation purposes and should be left unchanged.
