Allergy Immunotherapy Patient Consent Form

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PATIENT CONSENT FORM
ALLERGY IMMUNOTHERAPY
(ALLERGY INJECTION THERAPY)
Patient Name: ____________________________________________________________
Date: ___________________________________________________________________
Person Administering Consent: ______________________________________________
Dr. _____________________________________ has recommended immunotherapy (allergy injections) as
a form of treatment for you or your child. It is important for you to understand the nature of this treatment,
how it works, and possible side effects of it.
1. I understand that allergy immunotherapy (allergy injection therapy) is the process by which an “allergic”
patient is made less sensitive to a specific allergen (for example, pollens, animal dander, mold spores, dust
mite). This reduction in sensitivity is accomplished by repeated injections beneath the skin of the upper
arm of increases doses of extracts (mixtures) of these allergens. It is considered a common treatment for
allergic diseases.
2. I understand that allergy immunotherapy does not take the place of avoidance of allergens to which I am
known to be sensitized (allergic) and that the overall effectiveness of this injection treatment program also
depends on my complying with recommendations with respect to environmental controls, dietary
restrictions, and use of medications.
3. I understand that reduction of allergic sensitivity is the goal of allergen immunotherapy (allergy
injection therapy). Improvement is often not seen immediately, and may not be apparent for up to one year.
The results are often a reduction, but not complete elimination of symptoms. A few patients may not be
helped by immunotherapy at all. I recognize that there is no guarantee that this therapy will, in fact, result
in a cure or resolution of my symptoms.
4. I understand that allergy immunotherapy injections are usually given once or twice a week. In special
situations (cluster or accelerated allergen immunotherapy), several injections may be given daily. Once the
highest dose is attained (which may take several months), the frequency may be decreased to once a week,
twice a month, or once monthly. The total duration of immunotherapy is usually three to five years. I
understand that I should make myself available for periodic assessment by my physician in order to allow
my physician to determine if the therapy should be continued or altered.
5. I understand that allergy immunotherapy extracts are prepared under rigidly controlled conditions by
trained medical personnel. My allergy extract prescription is prepared according to my specific
sensitivities, and is not useable by any other patient. I understand that once the allergy extracts are
prepared, I am liable for the expense. Therefore, I recognize that I should contact my insurance company
to inquire about medical coverage of the allergy immunotherapy extracts before I sign this consent.
6. I understand that because my child or myself will be receiving injections of substances to which my
child or myself is allergic, reactions to the injections may occur. It is not unusual for swelling and itching
to occur at the site of an injection. Occasionally other reactions may occur. These reactions include:
generalized itching, hives, fainting, shortness of breath, or tightness in the throat or chest. I recognize the
possibility that life-threatening reactions could occur such as anaphylaxis, shock, and death, and although
rare, a few such cases have occurred in adults and children. I understand that I should avoid strenuous
exercise for two hours after my allergy injection therapy.

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