2021 / 2022 Allergen Order Form ご購入方法 注）ご注文書は全てローマ字でご入力/ご記入ください。注文書内の* 印の欄は入力必須項目です。 1. 注文者情報(Contact Person)、送付先(Shipping)、請求書宛先(Billing)、お支払い方法(Payment) をご入力ください。 2. 各アレルゲンを個別でご購入する場合は、ご注文の数を各アレルゲン横のボックス(qty) にご入力下さい。アレルゲンをシリーズや 種類・グループごとにまとめてご購入の場合は、ご注文の数を項目別一番上のグレーのボックス(qty) にご入力ください。 3. Eメール又はFAXでご注文：注文書PDFファイルを入力/記入後、添付書類としてEメールで送信の場合は [email protected] まで。FAXの場合は046-200-5626まで。 SERIES: シリーズ別..........選定されたリサーチグループによる推薦アレルゲン種。 GROUPINGS: グループ別..........国際的なリサーチグループや専門文献のレビューの推薦に基き、環境などによる接触の原因別によってあ らかじめセレクトされ た 濃 度 のアレル ゲン 種 CATEGORIES: カテゴリー別......商品タイプ別アレルゲン種（濃度の違う同一のアレルゲンが含まれている場合もあり）。 CONTACT PERSON *Required fields *First Name Last Name *Phone Fax *Email *Physician’s Name License # SHIPPING *Required fields BILLING *Required fields *Company Name *Company Name *Address *Address *City *City *State *Postal/ZIP *State *Postal/ZIP *Country *Country Use this address for my Billing Information METHOD OF PAYMENT *Required fields 銀行振り込み --- 振込先：三菱東京UFJ大和支店（普）0388950 カ）スマートプラクティスジャパン カナダ（ 30日以内に振込みをお願い致 します） Payment terms are Net 30 Days PRICING: 送料 1..................¥3,980/allergen <¥115,000 .................. ¥4,700 12~ .............¥3,860/allergen ¥115,001~¥225,000 ....¥5,200 720 28th Street NE, Suite #210 25~ .............¥3,740/allergen ¥225,001~¥335,000 ....¥7,000 Calgary, AB T2A6R3 (税別) ¥335,001~¥675,000 ..¥14,000 PHONE: 866.903.2671 FAX: 866.903.2672 | ¥675,001~ .................¥21,000 EMAIL: [email protected] 1 ALLERGEN ORDER FORM: SERIES SKU test substance %, vehicle qty SKU test substance %, vehicle qty series JP: Japanese Standard Series series AC: Core Allergen Series Complete JP series: 22 allergens Complete AC series: 87 allergens paraben mix [B] NA52 nickel sulfate hexahydrate ∞ 2.5 P methyl-p-hydroxybenzoate 3% ......................................AP100 NA53 propyl-p-hydroxybenzoate 3% .......................................AP105 12 P NA89 amerchol L101 50 P butyl-p-hydroxybenzoate 3% ...........................................AP81 ethyl-p-hydroxybenzoate 3% ...........................................AP92 NA51 neomycin sulfate 20 P EE353 petrolatum 100 P NA54 potassium dichromate ∞ 0.25 P NA31 DMDM hydantoin 1 P EM409 thimerosal ∞ 0.1 P NA38 fragrance mix (contains 5% SSO) µ 8 P eugenol 1% ...................................................................PF133 caine mix [A] geraniol 1% ...................................................................PF134 benzocaine 5% ��������������������������������������������������������������� NA13 cinnamic aldehyde 1% ................................................... NA19 LA525 cinchocaine-HCl 1% 7 P cinnamic alcohol 1% .....................................................PF129 tetracaine-HCl 1% ........................................................DM229 alpha-amylcinnamic aldehyde 1% ���������������������������������PF125 hydroxycitronellal 1% ....................................................PF135 MC254 gold sodium thiosulfate 0.5 P isoeugenol 1% ..............................................................PF137 oakmoss absolute 1% ���������������������������������������������������PF138 NA07 p-phenylenediamine 1 P NA24 colophony 20 P NA08 p-tert-butylphenol formaldehyde resin 1 P NA53 paraben mix [B] 12 P methyl-p-hydroxybenzoate 3% ......................................AP100 methylchloroisothiazolinone / propyl-p-hydroxybenzoate 3% .......................................AP105 NA09 ∑ 0.01 W butyl-p-hydroxybenzoate 3% ...........................................AP81 methylisothiazolinone ethyl-p-hydroxybenzoate 3% ...........................................AP92 NA12 balsam of peru (myroxylon pereirae resin) µ 25 P AP124 methylisothiazolinone ∑ 0.2 W NA15 black rubber mix 0.6 P NA12 balsam of peru (myroxylon pereirae resin) µ 25 P N-dimethyl-1, C-butyl-N-phenyl-p-phenylenediamine (DMBPPD) 0.25% NA35 ethylenediamine dihydrochloride 1 P diphenyl-p-phenylenediamine (DPPD) 0.25% ................RC274 N-isopropyl-N-phenyl-p-phenylenediamine (IPPD) 0.1% ST168 NA21 cobalt (II) chloride hexahydrate 1 P NA08 p-tert-butylphenol formaldehyde resin 1 P NA21 cobalt (II) chloride hexahydrate 1 P NA33 bisphenol A epoxy resin 1 P NA24 colophony 20 P NA18 carba mix 3 P 1,3-diphenylguanidine (DPG) 1% ...................................RC265 NA33 bisphenol A epoxy resin 1 P zinc bis(diethyldithiocarbamate) 1% ..............................ST162 zinc bis(dibutyldithiocarbamate) 1% ..............................RC268 NA37 formaldehyde ∑ 1 W NA15 black rubber mix 0.6 P N-dimethyl-1, C-butyl-N-phenyl-p-phenylenediamine (DMBPPD) NA51 neomycin sulfate 20 P 0.25% diphenyl-p-phenylenediamine (DPPD) 0.25% ................RC274 N-isopropyl-N-phenyl-p-phenylenediamine (IPPD) 0.1% ST168 NA52 nickel sulfate hexahydrate ∞ 2.5 P methylchloroisothiazolinone/ NA09 ∑ 0.01 W NA57 sesquiterpene lactone mix (2 ml) 0.1 P methylisothiazolinone alantolactone 0.033% costunolide 0.033% NA56 quaternium 15 2 P dehydrocostuslactone 0.033% NA07 p-phenylenediamine 1 P NA60 thiuram mix [A] 1 P tetramethyl thiuram monosulfide (TMTM) 0.25% ...........RC285 NA37 formaldehyde ∑ 1 W tetramethylthiuram disulfide 0.25% �������������������������������RC284 ∞ tetraethylthiuram disulfide (disulfiram) 0.25% ...............RC283 NA48 mercapto mix [A] 1 P dipentamethylenethiuram disulfide 0.25% .....................RC276 n-cyclohexyl-2-benzothiazyl-sulfenamide 0.333% dibenzothiazyl disulfide 0.333% NA64 lanolin alcohol 30 P morpholinyl mercaptobenzothiazole 0.333% NA03 2-bromo-2nitropropane-1, 3-diol (Bronopol™) 0.5 P NH451 primin (2 ml) 0.01 P NA60 thiuram mix [A] 1 P NA38 fragrance mix (contains 5% SSO) µ 8 P tetramethyl thiuram monosulfide (TMTM) 0.25% ...........RC285 eugenol 1% ...................................................................PF133 tetramethylthiuram disulfide 0.25% �������������������������������RC284 geraniol 1% ...................................................................PF134 tetraethylthiuram disulfide (disulfiram) 0.25% ...............RC283 cinnamic aldehyde 1% ................................................... NA19 dipentamethylenethiuram disulfide 0.25% .....................RC276 cinnamic alcohol 1% .....................................................PF129 amylcinnamic aldehyde 1% NA01 diazolidinyl urea (Germall ® II) 1 P hydroxycitronellal 1% ....................................................PF135 isoeugenol 1% ..............................................................PF137 NA13 benzocaine 5 P ST170 potassium dichromate ∞ 0.5 P NA61 tixocortol-21-pivalate 1 P MC254 gold sodium thiosulfate 0.5 P ST181 mercapto mix [C] ∞ 2 P N-cyclohexyl-2-benzothiazylsulphenamide 0.5% NA43 imidazolidinyl urea (Germall ® 115) 2 P dibenzothiazyldisulfide 0.5% 2-mercaptobenzothiazole 0.5% NA16 budesonide 0.1 P morpholinyl mercaptobenzothiazole 0.5% .....................RC294 NA93 hydrocortisone-17-butyrate 1 P NA18 carba mix 3 P 1,3-diphenylguanidine (DPG) 1% ...................................RC265 NA05 2-mercaptobenzothiazole 1 P zinc bis(diethyldithiocarbamate) 1% ..............................ST162 zinc bis(dibutyldithiocarbamate) 1% ..............................RC268 NA11 bacitracin 20 P NA70 fragrance mix II (contains 10% paraffin, hard) µ 14 P coumarin 2.5% lyral 2.5% citronellol 0.5% farnesol 2.5% citral 1% alpha-hexylcinnamic aldehyde 5% Liquid In Tube Volatile | P: petrolatum W: water E: ethanol 2 ALLERGEN ORDER FORM: SERIES SKU test substance %, vehicle qty SKU test substance %, vehicle qty NA83 disperse blue mix (124/106) 1 P PF128 benzyl salicylate* 1 P disperse blue-124 0.5% disperse blue-106 0.5% DC329 disperse yellow 3 1 P NA47 lidocaine-HCl 15 P NA76 jasminum officinale oil(jasminum grandiflorum) µ 2 P NA55 propylene glycol ∑ 30 W NA82 mentha piperita oil (peppermint oil) µ 2 P AP98 iodopropynyl butylcarbamate 0.2 P NA78 shellac ∑ 20 E EM405 polymyxin B sulfate 3 P EE374 lauryl glycoside (2 ml) 3 P NA22 cocamidopropyl betaine ∑ 1 W EE367 4-chloro-3-cresol (PCMC) 1 P mixed dialkyl thioureas NA88 diethylthiourea 0.5% 1 P dibutylthiourea 0.5% NA75 dimethylaminopropylamine (DMAPA) ∑ 1 W series NA: North American Standard Series NA72 2-hydroxyethyl methacrylate (HEMA) µ 2 P Complete NA series: 70 allergens NA80 oleamidopropyl dimethylamine ∑ 0.1 E NA13 benzocaine 5 P NA74 decyl glucoside 5 P NA05 2-mercaptobenzothiazole ∞ 1 P NA49 methyl methacrylate µ 2 P NA24 colophony 20 P NA81 lavandula angustifolia oil (lavender oil) µ 2 P NA07 p-phenylenediamine 1 P NA19 cinnamic aldehyde (contains 1% SSO) µ 1 P NA75 dimethylaminopropylamine (DMAPA) ∑ 1 W NA87 dl alpha tocopherol 100 NA70 fragrance mix II (contains 10% paraffin, hard) µ 14 P coumarin 2.5% NA34 ethyl acrylate 0.1 P lyral 2.5% citronellol 0.5% NA58 tea tree oil, oxidized 5 P farnesol 2.5% AP84 chlorhexidine diglucote ∑ 0.5 W citral 1% alpha-hexylcinnamic aldehyde 5% NH400 propolis [B] 10 P NA89 amerchol L101 50 P NA06 4-chloro-3,5-xylenol (PCMX) 1 P NA18 carba mix 3 P 2-hydroxy-4-methoxybenzophenone 1,3-diphenylguanidine (DPG) 1% ...................................RC265 NA85 (oxybenzone) 10 P zinc bis(diethyldithiocarbamate) 1% ..............................ST162 zinc bis(dibutyldithiocarbamate) 1% ..............................RC268 NA62 tosylamide formaldehyde resin 10 P NA51 neomycin sulfate 20 P sesquiterpenelactone mix (2 ml) alantolactone 0.033% NA60 thiuram mix [A] 1 P NA57 costunolide 0.033% 0.1 P tetramethyl thiuram monosulfide (TMTM) 0.25% ...........RC285 dehydrocostuslactone 0.033% tetramethylthiuram disulfide 0.25% �������������������������������RC284 tetraethylthiuram disulfide (disulfiram)