Allergy Vial Refill Request Form
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You must be a current allergy patient of Dr. Cobb or Dr. Gruhlkey and be able to give yourself shots outside the office to order allergy medications on-line.  Required fields are marked with the * symbol.
Please complete the following, then click "sumbit" to refill your shot vials.
 
Date
  
What was the highest dose that you received without increasing your allergy
symptoms or causing a large local reaction?  Fill in the amount (for example, .25, .5, etc.)  		 cc.
     

If you were not able to reach the suggested level of .5cc, please explain why below:
 
     
Do you want the vial mailed to you?   Yes   No   To what address? ($8.00 mailing fee applies)
Name*:   
   
Address: 
   
City:     State:   ZIP:  
   
   
Is this your current billing address?  Yes   No If not, please provide current billing address:  
  Name:
   
   Address:
   
   City:      State:   ZIP:  
   
     
 Contact phone numbers: 
Home* :   -  - 
   
Work* :   - -    ext:
(if same as Home enter "same")
Cell:   -  - 
   
     
Name of responsible party: 
   
Address: 
   
City:        State:    ZIP:  
   
     
Have you changed or started any new medications? * Yes No    
Have you become allergic to any medications since last seen by Dr. Cobb?
 
* Yes No If yes, please list (or indicate "none"):
 
Please list all medications that you now take for any problem:  
 

Do you require any prescriptions for your allergy medications?

 
List any refill prescription requests:
**This office cannot refill any medications not prescribed originally by Dr. Cobb
What pharmacy do you use? Name of Pharmacy* : 
   
City:
   
  Pharmacy's phone number: (800)  -  -  or   - - 
   
 
Allergy and Family Medicine POLICY: Any patient receiving an allergy injection outside the office must have a self-injecting Epi-Pen present when giving the injection and a medical release form signed and dated in our office.  If you have not given us a release, you may not order allergy vials on-line.