Patient Information Request

If you have pollen or food allergies, or asthma that may be caused by an allergic trigger we are here to help.

If your doctor is not offering the AllerAlt allergy drops please print this form and take it to them asking that he or she please prescribe you the AllerAlt allergy drops. Please note that should your doctor decide to begin prescribing the AllerAlt drops we will provide him, or her with a complimentary Starter Set for you to begin the Allergy drops treatment.

If your doctor is not interested in prescribing the AllerAlt drops and you would like to know if there is a doctor in your area who is prescribing the drops please complete the form below.

Referring Doctor Details

Patient Details