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* Date Format: MM slash DD slash YYYY Patient's First name*Patient's Last name*Patient's Date of birth* Date Format: 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: $200.00 Total $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.