AllerSmart IgE Order Form

Please fill out the following form to receive your return waybill.

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REPORT DISCLAIMER
The primary purpose of this test system is to identify IgE molecules reactivity to environmental and dietary allergen inhaled or contacted by the test subjects. The higher the class values, the greater the potential risk of an allergic reaction.

Test results are not intended as the sole source for clinical diagnosis. Treatment plans developed using the clinical data from this report require a trained professional proficient in managing
environmental allergies and immunotherapy. Before performing any treatment plan, medical necessity needs to be determined.

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I agree to AllerSmart IgE's Refund and Return Policy

I declare that the info I’ve provided is accurate & complete

PATIENT AUTHORIZATIONS & UNDERSTANDINGS
I consent to the collection, testing, and insurance claim filing of my blood for the purpose of the service noted above
(“SERVICE”).

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Thanks for submitting. You will receive a return waybill within 24 hours.

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AllerSmart IgE Order Form

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