Subcutaneous Immunotherapy Prescription Form	

Prescriber		Patient		
Name: 	 <<Doctor:Name>>    Prescriber: <<Doctor:Prescriber Number>>	Name:	 <<Patient Demographics:Full Name>>	
Practice:	 <<Practice:Name>>	Address:	 <<Patient Demographics:Address Preferred Line 1>> <<Patient Demographics:Address Preferred City>>	
Date	<<Miscellaneous:Date (short)>> 	   Ph: <<Doctor:Phone>>	Postcode:	 <<Patient Demographics:Address Preferred Postcode>>	
Email: 	<<Doctor:E-mail>>	Telephone:	 <<Patient Demographics:Phone (Home)>> (m) <<Patient Demographics:Phone (Mobile)>>	
Signature	
	Email: 	 <<Patient Demographics:E-mail>>	

Pricing		Delivery	
Initial sets ( I ) are $200 excluding GST, and
are sufficient for 4 months.	  	 Initial Set	q	Delivery costs $16.50 and will be by overnight courier from AMSL to the prescribing specialist or nominated GP	
	 	Doctor:    <<Doctor:Name>>	
Maintenance Sets ( M ) are $195 excluding
GST, and are sufficient for 5 months.	   Maintenance Set	q	Address:   <<Doctor:Address Line 1>> <<Doctor:Address Line 2>>, <<Doctor:City>> <<Doctor:Postcode>>	

Prescriber		Confirmation		
Doctor's Card 	q	Cardholder Signature	  AMSL will email a receipt of this prescription	 Email Patient  	q	
Patient's Card 	q		  to either the prescribing specialist or patient,     and arrange payment.	 Email Prescriber	q	
		Prescribing		
Name on Card:		Please to clearly mark each allergen
prescribed in the right hand column provided.		
Card Number: 				
Exp Date: 		<< Please note Amex incurs a 1.25% surcharge		

 Notes	

	

Personalised Allergen Mixes1	
Code	
%	

	

	

	

	

 
1 A maximum of (4) allergens may be combined.

	  Common Allergens	
     Code	
x	

Felis domesticus	
Cat	
E801*	

Canis lupus familiaris	
Dog	
E802	

Cavia porcellus	
Guinea pig	
E804	

Gallus gallus	
Chicken Feathers	
E806	

Equus caballus	
Horse	
E807	

Cynodon dactylon	
Bermuda/Couch grass	
G102*	

Sorghum halepense	
Johnson Grass	
G109	

Phleum pratense	
Timothy Grass	
G110*	

Hordeum vulgare	
Cultivated Barley	
G201*	

Triticum aestivum	
Cultivated Wheat	
G206*	

Holcus, Dactylis, Festuca, Poa, Lolium, Phleum	
6 Grass Mix	
MG51*	

Dermatophagoides ptero	
European dust mite	
M601*	

Dermatophagoides farinae	
American dust mite	
M602*	

Alternaria alternata	
	
P901*	

Aspergillus fumigatus	
	
P902*	

Candida albicans	
	
P904	

Penicillium nontatum	
	
P908	

Betula verrucosa	
Birch tree	
T502*	

Plantago lagopus	
Plantain	
W315	

Artemisia, Chenopodium, Salsola, Plantago	
Weed Mix	
MW57	

Full Allergen List overleaf	

 * Standardised Allergen	
Send to AMSL Allergy: Fax 02 9882 3999, or E-mail orders@amsl.com.au,
or Mail PO Box 5197, Chatswood West, NSW 1515	

Subcutaneous Immunotherapy Prescription Form	

  Trees and Pollens	
     Code	
x	

Acer negudo	
Maple	
T501	

Betula verrucosa	
Birch tree	
T502*	

Fagus sylvatica	
Beech	
T503	

Quercus pyrenaica	
Pyrennean Oak	
T505	

Quercus robur	
Red Oak	
T506	

Alnus glutinosa	
Alder	
T507*	

Fraxinus excelsior	
Ash	
T508	

Eucalyptus globulus	
Gum tree	
T509	

Syringa vulgaris	
Syringa tree	
T510	

Corylus avellana	
Hazel	
T511*	

Castanea sativa	
Chestnut tree	
T512	

Pinus sylvestris	
Scots Pine	
T513	

Thuja orientalis	
Oriental Thuja	
T514	

Tilia cordata	
Small leaved lime	
T515	

Morus alba	
White Mulberry	
T516	

Olea europaea	
Olive tree	
T517*	

Populus alba	
Poplar	
T518	

Ulmus campestris	
Elm tree	
T520	

Juniperus oxicedrus	
Juniper	
T521*	

Salix fragilis	
Willow tree	
T522	

Cupressus arizonica	
Arizona Cypress	
T523*	

Cupressus sempervirens	
Mediterranean Cypress	
T524*	

Quercus ilex	
Holm Oak	
T525	

Platanus hispanica	
London Plane	
T535*	

Pinus pinea	
Stone Pine	
T536	

Phoenix dactilfera	
Date Palm	
T537	

Pinus pinaster	
Maritime Pine	
T539	

Betula, Alnus, Corylus	
Mixed Trees 1	
MT54	

Populus, Ulmus, Salix	
Mixed Trees 2	
MT55	

Fagus, Quercus, Fraxinus	
Mixed Trees 3	
MT56	

Platanus, Populus, Quercus,
Betula, Alnus, Corylus	
Mixed Park Trees	
MT60	

  Grass and Grass Pollens	
      Code	
 x	

Holcus lanatus	
Yorkshire Fog	
G101*	

Cynodon dactylon	
Bermuda/Couch grass	
G102*	

Dactylis glomerata	
Cocksfoot	
G103	

Agropyron repens	
Couch Grass - American	
G104	

Lolium perenne	
Perennial Rye Grass	
G105*	

Anthoxanthum odoratum	
Sweet Vernal Grass	
G106	

Phragmites communis	
Common Reed	
G107	

Agrostis alba	
Redtop Grass	
G108*	

Sorghum halepense	
Johnson Grass	
G109	

Phleum pratense	
Timothy Grass	
G110*	

Poa pratensis	
Annual Grass	
G111*	

Festuca eliator	
Tall Fescue Grass	
G112*	

Paspalum notatum	
Bahia Grass	
G114	

Hordeum vulgare	
Cultivated Barley	
G201*	

Avena sativa	
Cultivated Oat	
G202*	

Trisetum paniceum	
Wild Oats	
G203*	

Zea mays	
Maize	
G204	

Secale cereal	
Cultivated Rye	
G205*	

Triticum aestivum	
Cultivated Wheat	
G206*	

Holcus, Dactylis, Festuca,
Poa, Lolium, Phleum	
6 Grass Mix	
MG51*	

Hordeum, Avena,
Secale, Triticum	
4 Cereals Mix	
MG52*	

MG51 + MG52	
6 Grasses + 4
Cereals Mix	
MG53*	

6 Grass Mix +
Cynodon dactylon	
6 Grass Mix +
 Couch Grass	
MG51
/G102*	

	
  Weeds	
     Code	
x	

Ambrosia eliator	
Common Ragweed	
W301	

Artemisia vulgaris	
Mugwort	
W302*	

Urtica dioica	
Stinging Nettle	
W303	

Amaranthus retroflexus	
Common Pigweed	
W304	

Chenopodium album	
Goosefoot	
W305	

Parietaria judaica	
Wall Pellitory	
W306*	

Sambucus nigra	
Elderberry	
W307	

Taraxacum officinale	
Dandelion	
W308	

Brassica napus	
Rape Seed	
W310	

Salsoli kali	
Russian Thistle	
W311*	

Rumex acetosella	
Sheep Sorrell	
W312	

Xanthium strumarium	
Cocklebur	
W313	

Plantago lanceolata	
English Plantain	
W314*	

Plantago lagopus	
Plantain	
W315	

Artemisia absinthum	
Wormwood	
W316	

Mercurialis annua	
Annual Mercury	
W317	

Kochia scoparia	
Burning Bush	
W319	

Artemisia, Chenopodium, Salsola, Plantago	
Weed Mix	
MW57	

  Animal Epithelia and Feathers	
     Code	
x	

Felis domesticus	
Cat	
E801*	

Canis lupus familiaris	
Dog	
E802	

Oryctolagus cuniculus	
Rabbit	
E803	

Cavia porcellus	
Guinea pig	
E804	

Cricetus cricetus	
Hamster	
E805	

Gallus gallus	
Chicken Feathers	
E806	

Equus caballus	
Horse	
E807	

Bos taurus	
Cow	
E808	

Ovis aries	
Sheep	
E809	

Sus scrofa	
Pig	
E810	

Mus musculus	
Mouse	
E811	

Rattus rattus	
Rat	
E812	

Anser spp.	
Goose Feathers	
E815	

Anas platyrhyncha	
Duck Feathers	
E816	

Capra hircus	
Goat	
E817	

Columba livia	
Dove Feathers	
E819	

  Mites and Insects	
           Code	
x	

Dermatophagoides ptero	
European dust mite	
M601*	

Dermatophagoides farinae	
American dust mite	
M602*	

Lepidoglyphus destructor	
Dust mite	
M603*	

Tyrophagus putrescentiae	
Mould mite	
M604	

Acarus siro	
Flour mite	
M605	

Chortoglyphus arcuatus	
Storage mite	
M606	

Euroglyphus maynei	
House dust mite	
M607	

Blomia tropicalis	
Tropical mite	
M608	

Euroglyphus domesticus	
House dust mite	
M609	

Dermatophagoides microceras	
House dust mite	
M610	

Blatella germanica	
German cockroach	
I701	

Blatta orientalis	
Oriental cockroach	
I702	

Periplaneta Americana	
American cockroach	
I703	

D pteronyssinus + Dfarinae	
HDM mix	
M601/M602	

  Moulds	
       Code	
 x	

Alternaria alternata	
	
P901*	

Aspergillus fumigatus	
	
P902*	

Candida albicans	
	
P904	

Cladosporium herbarum	
	
P905	

Penicillium nontatum	
	
P908