Allergy Immunotherapy Patient Consent Form (Page 2 of 2) in pdf

7. I understand that allergy injections should be administered in a medical facility. A trained medical

person under the supervision of a physician who is immediately available to treat any possible adverse

reaction should give these injections. I am required to be observed for a period of at least 30 minutes

following an injection in a medical setting. I also understand that I must report any problems that I might

recognize or suspect as resulting from an allergy injection to the staff of this office BEFORE receiving any

additional allergy injections.

8. I understand that if I have any question about whether I should receive immunotherapy, I should discuss

this with my physician now or at the time of any injection. Generally, I understand that I should not

receive an injection if I am having a fever, wheezing, or hives. I also should not receive an injection if my

asthma is under poor control as evident by decreased peak flows, usually less than 70% of my best peak

flow readings (yellow/red zone).

9. I understand that allergy injections cannot be given to patients who are currently taking beta-blocker

medications. Examples of beta-blockers include, but are not limited to Inderal, Lopressor, metoprolol,

atenolol, Coreg, Toprol, and propanolol. Beta-blockers may be given for a variety of conditions including

hypertension (high blood pressure), angina (heart pain), thyroid disease, arrhythmias (abnormal heartbeat),

certain psychiatric disorders (panic attacks), and glaucoma (elevated eye pressure). I understand that you

should consult your physician or pharmacist regarding any uncertainty about a specific medication that I

may take. I understand that I will consult my physician if any changes are made in my medication regimen

once allergy immunotherapy is initiated.

10. If allergy injections are received OUTSIDE of THIS office and administered at another medical

facility, we believe that the person or physician administering the injection must assume complete

responsibility for any side effects or adverse reactions resulting from the allergy injection.

PATIENT’S CONSENT: I have read and fully understand this consent form, and consent to be treated

with allergy injection therapy. I understand that I should not sign this form if all items, including all of my

questions, have not been explained or answered to my satisfaction or if I do not understand any of the items

or words contained in this consent form.

If you have any questions as to the risks or hazards of the proposed treatment or any questions concerning

the proposed treatment, ASK YOUR DOCTOR NOW BEFORE SIGNING this consent form.

DO NOT SIGN THIS CONSENT FORM UNLESS YOU HAVE READ AND THOROUGHLY

UNDERSTAND ITS CONTENTS.

__________________________________ ________________________________________________

Print Name of Patient

Signature of Patient/Parent/Guardian

Date

Time

__________________________________ ________________________________________________

Print Name and Job Title of Witness

Signature of Witness

Date

Time

Facility where injections will be given: __________________________________________________

__________________________________________________________________________________

Physician signature

Date Time

Allergy Immunotherapy Patient Consent Form Page 2