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Request Account

Thank you for Registering for an account to the Allergen Extract Lab Management System.
In order for your account to be approved we will need your current curriculum vitae and a signature card. This information can be faxed to us at XXX-XXX-XXXX. Only board certified (American Board of Allergy and Immunology) and board eligible physicians are authorized to initiate therapy for allergen extract vaccines. New prescriptions written by a non-board certified physician must be reviewed and cosigned by a regional Allergist. For refill prescriptions, attending and clinic directing physicians (non-Allergists) are authorized to prescribe for continued therapy.

Please fill out the account request form below. Your new account information will be emailed to you if your account is approved.

Fields marked with an asterisk * are required.
Account Information
First Name *
Last Name *
User Type *
Email Address *
Fax Number
Phone Number *
Security Question *
Security Answer *
Location *
(All Facilities You Support)
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