Transcription of ALLERGY ORDER FORM
1 ALLERGY ORDER FORMNEED SUPPLIES? Check here or go to TO HISTORY FORM ANTIBODY TITER TESTINGRAN @ NEXTMUNE S FACILITIES CANINE VACCICHECK (1)please submit serum/whole blood protection for Parvovirus, Distemper & infectious Hepatitis. PURCHASE IN-CLINIC TEST KITS CANINE VACCICHECK KIT (12) CANINE VACCICHECK LAB PACK (120) ALLERGY TESTINGADD-ON OPTIONSINDIVIDUAL PANELS REGIONAL PANEL (53 ALLERGENS) Includes regional inhalant allergens COMPREHENSIVE FOOD PANEL (small animal only)24 Most common commercial pet food ingredients SPOT PLATINUM+ TEST ONLYI ncludes weeds, trees, grasses, epidermals, foods, mites, molds, staph, insects, Malassezia, indoor (or barn) allergensBEST VALUE TEST & TREAT PACKAGE SubQ Injections Sublingual Drops Wait for ResultsIncludes 1 SPOT Platinum+ ALLERGY Test & Initial Treatment of your choice1.
2 2. SPECIAL ORDER ALLERGENS EXPANDED FOOD PANEL (small animal only)24 Additional commercial pet food ingredients EFFECTIVE v1 EFFECTIVE v1 Please complete this form as fully as possible, including history form. Return form with sample as per delivery instructions. No Steroid Withdrawal required // 3-5 mls of SerumVeterinarianClinicAddressCity State ZipPhone ( ) Fax ( )Nextmune OnlyAnimal s First Name Last Name Canine Feline EquineBreed Age DateWeight: Over 22 lbs Under 22 lbsSex: Male Neutered Female Spayed Previously tested with Nextmune | Spectrum | ACTTDate Rcvd:_____Purchase ORDER #: Results Emailed to: 2801 S.
3 35th St. | Phoenix, AZ 85034 | | HISTORY FORMNEXTMUNE HISTORY FORMP lease complete and return with ORDER form* As of Jan. 1, 2014 we are no longer offering retesting on our own results at half price, except for food panels. If you have a patient that isn t performing well on treatment please contact Technical Services for additional ALLERGY NOTES_____CANINE / FELINE PATIENTS1. Current ALLERGY Symptoms are: Skin Issues Respiratory Issues GI Issues Other _____2. What age did the symptoms begin? _____3. Has the animal ever been tested for allergies in the past? Yes* No If yes: by Nextmune | Spectrum | ACTT Lab No. _____ by other means. Specify _____ Has patient been on hyposensitization treatment?
4 Yes No When? _____4. Has the animal ever been on relief meds? Yes No What: _____ When: _____ 5. What foods do you feed? Canned Dry Table ScrapsBrand: _____ Other: _____6. Exposed to other animals? Dog Cat Bird Other: _____EQUINE PATIENTS1. Current ALLERGY Symptoms are: IBH/Hives Respiratory Issues Hair loss Other _____2. What age did the symptoms begin? _____3. Has the animal ever been tested for allergies in the past? Yes* No If yes: by Nextmune | Spectrum | ACTT Lab No. _____ by other means. Specify _____ Has patient been on hyposensitization treatment? Yes No When?
5 _____4. Describe the stable environment (other animals, insects, climate, etc) _____ _____5. Describe horse s diet: _____ _____6. How have the horse s symptoms been treated in the past? _____ _____Date: _____Animal s Name: _____Animal s Age: _____ Sex: _____Veterinarian: _____Owner: _____ Dog Cat Horse Breed: _____
