Outgoing Immunotherapy Serum Transfer Outgoing Immunotherapy Serum TransferName* First Last I would like to transfer my immunotherapy serums from Raffi Tachdjan, MD to:Doctor's Name* First Last Office Name*Office Phone*Office FaxOffice Address* 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 PLEASE NOTE: We MAY need to make new vials IF your current vials are nearing their expiration date or if your current vials contain less than 3 month’s worth of serum. If this is the case, we will notify you and will remake a year’s worth of serum and bill your insurance* accordingly. It can take UP TO 2 WEEKS for our office to complete an outgoing serum transfer. Please plan accordingly.In order to transfer your serums, you need to have established care with the office above.*No, I have not had a visit at this office yet.Yes, I have had at least one visit at this office.The date for my first visit is:* Date Format: MM slash DD slash YYYY I need my serums at this office by:* Date Format: MM slash DD slash YYYY You have the option of transporting your serums yourself or having Raffi Tachdjan, MD ship your serums overnight (you will be responsible for the shipping charge).*I choose to transport my serums myself, accepting responsibility for proper care of the vials.I choose to have AIRE Medical ship my serums overnight.Product Name Price: $100.00 Credit Card Billing Address* 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 Email Receipt To:* Enter Email Confirm Email Credit Card* Cardholder Name Card Details Signature**As always, it is your responsibility as the patient to ensure we have your most updated and current insurance information BEFORE services are rendered. Failure to do so may result in postponed services and/or erroneous, expensive bills.PhoneThis field is for validation purposes and should be left unchanged.
