Consent for Allergy Testing and Treatment

I understand that allergy skin testing and immunotherapy is a form of treatment that has certain advantages and disadvantages. The advantages of immunotherapy are that oftentimes the need for medications can be reduced and/or eliminated and that otherwise uncontrollable symptoms may be better controlled.

I also understand that any form of medical therapy may be ineffective or provide only partial relief, including this form of allergy therapy. I understand also that it may have adverse side effects including, but not limited to: local reactions at the injection sites with redness, swelling, and discomfort; worsening of allergy symptoms with runny nose, nasal congestion, itching, difficulty breathing, worsening of asthma symptoms, and anaphylactic shock (a severe drop in blood pressure with swelling of various structures of the body including possible swelling of the airway).

I have informed the allergy staff and physician of all of the medications I am currently taking or have taken in the recent past. This includes any eye drops, blood pressure medication, steroids (Prednisone, Medrol Dose Pack), antidepressants, and allergy medications. If I neglect to inform them of the medications, I understand that there may be side effects when performing the allergy testing and/or allergy injections, and I take full responsibility for this.

I also understand that discontinuing the injections or taking the injections irregularly may result in worsening of my allergy symptoms and/or triggering some of the above-mentioned reactions when given a shot.

I give my consent for allergy testing and immunotherapy with full knowledge of the above information.

The insurance pre-certification we received at our office for your allergy tests is not a “guarantee of coverage or payment” by your insurance company. You are ultimately responsible for the charges if the insurance company fails to pay for the tests (in part or its entirety).

Date: __________________     Patient Name: ________________________________________

Signature of Patient or Legally Responsible Party

Date: ___________________   Witness: _____________________________________________