IMMUNOTHERAPY ORDER FORM
:::::::::::::::::::::::::::: STANDARD :::::
IDEXX Reference Laboratories
For new and re-orders, please remember to include a copy
of all 5 pages of the relevant Special Import Certificate
(SIC) from the Veterinary Medicines Directorate (VMD).
This form is used with our allergy assessment programme.
If you require an expanded selection of allergens, please call 00800 1234 3399.
FAX 01937 544 001
date
patient name
delivery address
owner name
SPECIES
FOR RE-ORDERS: do not tick boxes, rather please provide the serial number from the side of the vial.
You must obtain a new SIC from the VMD.
___ ___ ___ ___ ___ / ___ ___ ___ ___ ___ ___
IDEXX VETcode
prescribing veterinary surgeon
VMD certificate number
signature of prescribing veterinary surgeon
V M D10235 / ___ ___ ___ ___ / ___ ___ ___ ___ ___
You may select as many allergens as necessary. Please note that there are
four price bands: 1 to 4 allergens, 5 to 8, 9 to 12, and 13 to 16. For orders of
more than 8 allergens, the immunotherapy will be supplied in two vials.
Grass Pollen
To arrange a consultation with a board-certified dermatologist,
Mites
please call 00800 1234 3399
IDEXX Code
110

House dust mite (D. farinae)
Orchard (Dactylis glomerata)
106

House dust mite (D. pteronyssinus)

Meadow (Poa pratensis)
111

Storage mite (Tyrophagus spp)

Perennial rye grass (Lolium perenne)
109

Grain mite (Lepidoglyphus spp)
N

Storage mite (Acarus spp)
M

Timothy (Phleum pratense)

Mixtures
IDEXX Code
L
For pricing purposes, the
mixtures are considered to be
one allergen
I
O

Pollen from weeds and flowers
Tree pollen mixture 1
Epithelia
Sheep sorrel (Rumex acetosella)
206

English plantain (Plantago lanceolata)
205

Stinging nettle (Urtica dioica)
209

Lamb’s quarter (Chenopodium album)
204

Mugwort (Artemisia vulgaris)
203

Alternaria alternata
707

Ragweed, short (Ambrosia artemisifolia)
202

Cladosporium herbarum
708
706

Cat epithelium (Felis domesticus)
R

Tree pollen mixture 2
Fungi

Wall pellitory (Parietaria officinalis)
219

Aspergillus fumigatus

Clover (Trifolium)
222
N/A
Penicillium

Cladosporium herbarum

Tree pollen mixture 3
Birch (Betula populifolia)
303

Alder (Alnus spp )
330
N/A
Weed pollen mixture 1
Stinging nettle, Mugwort (common)
See Tree pollen mix 2

Oak (Quercus spp)

Cypress (Cupressus spp)
345

Beech (Fagus sylvatica)
342

Poplar (Populus spp)
328

Hazel (Corylus avellana)

Elm (Ulmus spp)

Maple (Acer pseudoplantanus)
301

Willow (Salix caprea)
346

Olive/Ash (Olea europaea/Fraxinus excelsior)
310
N/A
Cedar (Chameacyparis spp)
Other Allergens
Please specify:
Black fly (Simulium spp)
Mosquito (Aedes communis;
909
subgenera of Culex)

Cockroach (Periplaneta americana
subgenera of Blattaria)
327
N/A
Horse fly (Tabanus spp)
316
N/A
Stable fly (Stomoxys spp)
N/A
Midges (Culicoides spp)
908
Malassezia

Malassezia
777
D
Poplar, Sycamore, Willow, Olive/Ash

R
Insects

N/A
C
Oak, Elm, Beech
Pollen from trees and hedges
UK110-1212
B
Birch, Alder, Hazel

N/A: not available; please consult with
our dermatologists for alternatives.
IDEXX Code
G