order form - Allergy Therapeutics
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UK CUSTOMER ORDER FORM Hospital/Pharmacy: Account Number: Tel: Fax: Email: Consultant/Doctor: Tel: Fax: Email: Invoice Address: Delivery Address: Please provide patient details when ordering Named Patient Products: Name: Date of birth: Pollinex (Licensed Product) 1960 2160 Please tick therapy required Pollinex Grasses + Rye (vials 1,2,3,3) Pollinex Trees (vials 1,2,3,3) Pollinex Quattro (Named Patient Product) Ref No: Please state percentage required *When ordering treatment year 2 and 3 please provide previous reference number 4130 4250 4204 4007 4601 4982 4983 4503 4957 Grasses + Rye Pollen 3 Tree Pollen (Birch/Alder/Hazel)* Birch Pollen Plantain Pollen Mugwort Pollen Olive Pollen Parietaria Pollen Fat Hen Pollen Ragweed Pollen *Please note that if 3 Tree Pollen is ordered only one other allergen can be included which cannot be Birch Pollen ATCF-212 Allergy Therapeutics Ltd Dominion Way Worthing West Sussex BN14 8SA Oralvac Compact (Named Patient Product) Please tick the treatment required: Initial course (vials 1,2,3,3) Maintenance course* (vials 3,3) Ref No: *When ordering a maintenance course please provide previous reference number 4100 1100 1300 2800 2801 4204 3204 3205 4007 4201 4207 4601 4957 4961 4982 4983 4009 Please state percentage required B2 Grass Pollens Alternaria alternata Cladosporium cladosporioides House Dust Mite: Dermatophagoides farinae House Dust Mite: Dermatophagoides pteronyssinus Birch Pollen Cat Fur Dog Hair Plantain Pollen Alder Pollen Hazel Pollen Mugwort Pollen Ragweed Pollen Cultivated Rye Pollen Olive Pollen Parietaria Pollen Cypress Pollen Tyrosin TU t.o.p.(Named Patient Product) Please tick the treatment required: Initial course (vials 1,2) Maintenance course* (vial 2) Ref No: *When ordering a maintenance course please provide previous reference number 1100 1300 2800 2801 3203 3204 3205 4006 4007 4100 4201 4202 4203 4204 4207 4209 4210 4503 4601 4957 4961 4982 4983 Please state percentage required Alternaria alternata Cladosporium cladosporioides House Dust Mite: Dermatophagoides farinae House Dust Mite: Dermatophagoides pteronyssinus Horse Hair Cat Fur Dog Hair Nettle Pollen Plantain Pollen B2 Grass Pollens Alder Pollen Ash Pollen Beech Pollen Birch Pollen Hazel Pollen Oak Pollen Plane Pollen Fat Hen Pollen Mugwort Pollen Ragweed Pollen Cultivated Rye Pollen Olive Pollen Parietaria Pollen ATCF-212 Allergy Therapeutics Ltd Dominion Way Worthing West Sussex BN14 8SA DAP - Penicillin Allergic Determinants DAP Penicillin DAP Amoxicillin DAP Clavulanic 8130 002 030 8131 002 030 8134 002 030 8136 002 030 8135 002 030 8137 002 030 8138 002 030 6 Pack 12 Pack Diluent Pack 3 Pack 6 Pack Diluent Pack Allergen Range for Skin Prick Testing 1100 1300 2800 2801 3203 3204 3205 4006 4007 4100 4204 4207 4944 5101 5201 5202 2000 2705 2804 3507 3508 4009 4110 4200 4201 4202 4203 4205 4209 4210 4212 4214 4403 4503 4601 4602 4702 4800 4904 4957 4961 Please state quantity of packs required Please state quantity required Alternaria alternata* Cladosporium cladosporioides* House Dust Mite: Dermatophagoides farinae* House Dust Mite: Dermatophagoides pteronyssinus* Horse Hair* Cat Fur* Dog Hair* Nettle Pollen* Plantain Pollen* B2 Grass Pollens* Birch Pollen* Hazel Pollen* Poplar Pollen* Wheat Grain* Egg, whole* Milk, cow* Aspergillus Fumigatus Cockroach (mixed) Blomia Tropicalis Guinea Pig Hair Hamster Hair Cypress Pollen Timothy Grass Pollen B3 Tree Pollen* Alder Pollen Ash Pollen Beech Pollen Elm Pollen Oak Pollen Plane Pollen Willow Pollen Russian Thistle Dandelion Pollen Fat Hen Pollen Mugwort Pollen Orache Pollen Chrysanthemum Pollen B5 Weeds and Shrubs Pollen* Bermuda Grass Pollen Ragweed (short) Pollen Cultivated Rye Pollen ATCF-212 Allergy Therapeutics Ltd Dominion Way Worthing West Sussex BN14 8SA Allergen Range for Skin Prick Testing continued Please state quantity required 4974 Rape Pollen 4982 Olive Pollen 4983 Parietaria Pollen 4993 Maple Ash (Acer negundo) 5601 Cod 6100 Almond Nut 6124 Celery 6128 Hazelnut Nut 6184 Plain Flour 6185 Soya Flour 6354 Rye Flour 8630 Salmon 6371 Histamine 1% 1908 Negative Control 4792-001-110-3 Lancets x 200 4803-000-110-1 Allergy Gauge Empty 50 Vial Diagnostic Box * Licensed products Note: The skin prick vials contain 2mls of solution, enough for 80 – 100 tests. For expiry date please refer to individual vials. If the 8 Vial Diagnostic box is requested then all of the items below MUST be ticked. Please tick each box 8 Vial Diagnostic Box 4792-001-110-3 Lancets x 200 4803-000-110-1 Allergy Gauge Pen 6371 Histamine 1% 1908 Negative Control The 8 vial diagnostic box will contain one of each of the following allergens: 4100 1100 4204 4207 2800 2801 3204 3205 B2 Grass Pollens Alternaria alternate Birch Pollen Hazel Pollen House Dust Mite: Dermatophagoides farina House Dust Mite: Dermatophagoides pteronyssinus Cat Fur Dog Hair Please fax form to Market Support Department on 01903 844744 or email atlorders@atplc.co.uk If you have any queries please telephone 01903 844700 ATCF-212 Allergy Therapeutics Ltd Dominion Way Worthing West Sussex BN14 8SA
