Immunotherapy/Allergy Vaccine Request

This service is for existing clients and patients receiving immunotherapy/allergy vaccines who need refills of an existing prescription. Please place your refill order when you have 1-2 doses of immunotherapy remaining on your current prescription. Orders generally take about 1-2 weeks to process and ship.

If you are a new or existing client and are interested in starting immunotherapy for your pet, please contact us at 919-513-6543.

Name of the patient/pet? Name of the owner (First/Last)? Phone number where we may reach about your order? When was the immunotherapy started (month/year)? When was the patient last seen by the Dermatology service at NCSU-CVM? Who was the last veterinarian to see the patient on the Dermatology service at NCSU-CVM? Is the patient still receiving immunotherapy?

Yes

No

If yes, what are the current amount of allergens and frequencies of injections?
Do you see any side effects from immunotherapy injections?

Yes

No

Unsure

If yes or unsure, please describe any side effects or concerns? (Ex: hives, swelling, increased scratching, redness, other) How many flares of signs of allergy (red skin lesions/itching/scratching/biting/chewing/licking) occurred in the last month?

0

1-3

more than 3

Please describe the allergic signs that occurred during the flare How many flares of signs of allergy (red skin lesions/itching/scratching/biting/chewing/licking) occurred in the last 3 months?

0

1-3

more than 3

Please describe the allergic signs that occurred during the flare Overall, do you think that the immunotherapy has been effective in reducing signs, preventing flares or reducing the usage of anti-allergic drug in your pet?

not effective at all

somewhat effective

fairly effective

very effective

Comment Do you think that the benefit of this immunotherapy protocol is worth its expense and hassle?

Yes

No

Comment Would you like to continue it?

Yes

No

Comment

Medications

Is your pet receiving, or received in the last year, any of the following medications:

Steroids including topicals/orals (prednisone, prednisolone, Temaril-P, Genesis spray, Mometamax, Mupirocin)?

Atopica/Cyclosporine/Ketoconazole/Fluconazole?

Antihistamines (Benadryl, Diphenhydramine, Zyrtec, Cetirizine, Claritin, Hydroxyzine)?

Other medications not listed above?

Please provide the product name, dose, frequency and duration of any medication your pet is receiving or has received in the last year. For example: Prednisolone, 10mg once daily for 14 days from 8/14/11 – 8/28/11. If you’re unsure of the exact details of the medications or administration, please provide as much information as possible. Do you have any questions or concerns not addressed in the form? Effective 10/1/2011, all new and existing patients receiving immunotherapy from the Veterinary Dermatology Service at the NC State University RB Terry Veterinary Medical Center will need to be seen for an office visit by one of our dermatologists at least once per year. If your pet has not been examined by one of our dermatologists in the past year, please call 919-513-6543 to schedule an appointment. Please check the box on the top left that you have read and understood this requirement.

Please enter your email address in the box below if you would like to receive an email copy of your submission.