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Immunotherapy Prescription Forms

As a members-only benefit, the forms can be edited and customized for individual practices.

Documentation for Allergen Immunotherapy Prescription: Recommended Guidelines (Word)

Documentation for Allergen Immunotherapy Prescription: Recommended Guidelines (PDF)
 

Maintenance Concentration Prescription Form (Word)

Maintenance Concentration Prescription Form (PDF)
 

Maintenance Concentrate Prescription Form w/expiration dates (Word)

Maintenance Concentrate Prescription Form w/expiration dates (PDF)
 

Maintenance Concentrate Prescription Form—completed example (Word)

Maintenance Concentrate Prescription Form—completed example (PDF)
 

Allergen Immunotherapy Mixture ComponentsD (Word)

Allergen Immunotherapy Mixture Components (PDF)

The immunotherapy prescription and administration forms are based on the Joint Task Force on Practice Parameters Allergen Immunotherapy (first through third updates).

 

By accepting the Terms of Use on preceding pages, you agree that these forms are being provided for educational and informational purposes only and are not intended to be a substitute for your independent medical judgment. The AAAAI is not liable for any decision made, or action taken by you or anyone else, in reliance upon the information contained within these forms.