Patient History Form

This form is only needed for new customers that wish to order the “Medical Grade’ allergy drops.

*Anaphylactic Reaction – Severe reaction characterized by difficulty breathing due to throat swelling and/or loss of consciousness.
*Beta Blockers – Propanolol, Sotalol, Timolol, Pindolol, Levobunolol, Nadolol, Metipranolol, Atenolol, Acebutolol, Metoprolol, Bisoprolol, Esmolol, Betaxolol, Nebivolol.