Order Slit – Sublingual Immunotherapy Please Allow Two (2) Weeks For Delivery. If This Is Your First Time Ordering Drops, You MUST Pick Them Up In The Office. Order Slit Date* MM slash DD slash YYYY Patient's First name* Patient's Last name* Patient's Date of birth* MM slash DD slash YYYY Phone number*Secondary phone numberEmail* Shipping / Pick Up*Please select oneShip to homePick up at office (please allow 2 weeks)Product Name* Price: SLIT $200.00 PayPal fee $7.00Total $0.00 SLIT Subscription Option*Do you wish to subscribe for an automated renewal of your SLIT order to be placed every 6 weeks?Please select oneNo, I would like to make a one time purchase.Yes, please renew my order automatically every 6 weeks!Confirm* By checking this box, I affirm that I have read and agree to Acadiana Allergy Center’s terms and conditions and the following statement: I authorize Acadiana Allergy Center to charge me for the order total. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept Acadiana Allergy Center’s business terms as published on their website. By pressing the Submit Order button below, I agree to pay Acadiana Allergy Center. Δ
