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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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:* MM slash DD slash YYYY I need my serums at this office by:* 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 Raffi Tachdjan MD, inc. to ship my serums overnight. Product Name Price: Credit Card Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Receipt To:* Enter Email Confirm Email Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name 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.CommentsThis field is for validation purposes and should be left unchanged.
