Immunotherapy Request Form

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Please use this form to request that an order is placed for your child's immunotherapy.

If we do not have your credit card details on file you will be contacted for your details.

Please note: the supplier will not process an order without the correct credit card details.

Please allow up to 8 weeks for your order to be delivered to the clinic or to your treating doctor.

If after 8 weeks you have not received a notification that your order has been delivered please contact us on 9369 5757.

Your child's full name? *

Your child's date of birth? *

YYYY

Which Allergist sees your child at The Children's Clinic? *

Has your child already started or previously received immunotherapy?

Yes

No (This is the first order)

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Current Immunotherapy? *

How much immunotherapy would you like to order?

1 Box of 30 tablets (Actair or Acarizax only)

2 Boxes of 30 tablets (Actair or Acarizax only)

3 Boxes of 30 tablets (Actair or Acarizax only)

1 Box of 90 Tablets (Actair or Acarizax only)

1 Kit (Oralek or Injections only). Lasts approx 5 months.

2 Kits (Oraltek or Injections only). Lasts approx 10 months.

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Where does/will your child receive their immunotherapy? *

At home (oral formulations only)

At The Children's Clinic

At your usual GP

At a doctor other than the usual GP

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