To refill your vaccine, fax your reorder to (804) 739-9006 or simply fill out the form below. Name*Patient Year of Birth (i.e. 1984)*PhoneWhich doctor ordered your Allergy Vaccine?*Barry K. Feinstein MDMargaret H. Sigman, MDConcentration Requested*1:10 (red)1:100 (gold)1:1000 (blue)Frequency of Injections*Every WeekEvery 2 WeeksEvery 3 WeeksMonthlyNumber of Bottles in Set*12Date of Last Injection Delivery Options*Mail to Address BelowMidlothian Office (Harbour Park)West End Office (Parham Road)Shipping Address (if not picked up in office) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Insurance CompanyEmail I authorize Advanced Allergy and Asthma to make and send my vaccine. I have checked to be sure I have a referral (if applicable) from my insurance prior to ordering today* I Agree UntitledName First Last NameThis field is for validation purposes and should be left unchanged.