Immunotherapy Prescription Forms

By accepting the Terms of Use, 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.

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

2a Documentation for Allergen Immunotherapy Prescription Recommended Guidelines (Word)
2a Documentation for Allergen Immunotherapy Prescription Recommended Guidelines (PDF)

2b Maintenance Concentrate Prescription Form (Word)
2b Maintenance Concentrate Prescription Form (PDF)

2b1 Extract Formulation (Word)
2b1 Extract Formulation (PDF)

2c Maintenance Concentrate Prescription Form Completed Examples (Word)
2c Maintenance Concentrate Prescription Form Completed Examples (PDF)

2d Guidelines for Allergen Immunotherapy Extract Label Documentation (Word)
2d Guidelines for Allergen Immunotherapy Extract Label Documentation (PDF)

2e Allergen Cross Reactivity Patterns (Word)
2e Allergen Cross Reactivity Patterns (PDF)

2f Probable Effective Dose Range for Standardized and Nonstandardized Extracts (Word)
2f Probable Effective Dose Range for Standardized and Nonstandardized Extracts (PDF)

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

12/3/2024