Prepared by: ________________ Date Prepared:__/__/__ Antigen Extract Name Concentration and Volume of Extract Number Expiration Number Allergen or Diluent Type Manufacturer’s Manufacturer Date (Common name or Manufacturer’s Extract to Add Genus/species )* Extract (AU, BAU, W/V, PNU)/ (50% G, Aq, Ly, AP) 1 2 3 4 5 6 7 8 9 10 Diluent Total Volume * Components of mixes listed on a separate sheet Specific Instructions: ___________________________________________
Prepared by: ________________ Date Prepared:__/__/__ Antigen Number Extract Name Allergen or Diluent (Common name or Genus/species )* Concentration and Type Manufacturer’s Extract (AU, BAU, W/V, PNU)/ (50% G, Aq, Ly, AP) Volume of Manufacturer’s Extract to Add Extract Manufacturer Number Expiration Date 1 2 3 4 5 6 7 8 9 10 Diluent Total Volume * Components of mixes listed on a separate sheet Specific Instructions: ___________________________________________