Antigen Reorder Form

Notice: Please allow two working weeks’ notice when reordering your Antigens.
PLEASE LET US KNOW IF YOU HAVE ANY CHANGE IN YOUR INSURANCE INFORMATION.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Located on the back of your insurance card
  • I understand that referrals are my responsibility and that I may be responsible for payment for any service rendered that is not covered due to not having a current referral.
  • This field is only required if you are having your antigens mailed. Please include the clinic name if applicable.
By clicking “Submit” you are agreeing that you understand that these antigens are mixed specifically for you and that, once mixed, you are responsible for any costs not covered by your insurance.