Agreement to Carry an EpiPen
An EpiPen 2-Pak (auto-injector of Epinephrine) and Benadryl must be available on the day of an allergy injection, even if you have been on injections for multiple years. Epinephrine is the first line of medication given for anaphylaxis (life threatening symptoms). If life threatening symptoms are going to occur, there is a 97% incidence that they will occur within 20-30 minutes after the allergy injection but could occur up to 6 hours later.
The most distinctive symptoms of anaphylaxis include:
- Swelling of the throat, lips, tongue, or around the eyes
- Difficulty breathing or swallowing
- Hives
Other common symptoms of anaphylaxis may include:
- Metallic taste or itching in the mouth
- Generalized flushing, itching, or redness of the skin
- Abdominal cramps, nausea, vomiting, or diarrhea
- Increased heart rate
- Sudden decrease in blood pressure (and accompanying paleness)
- Sudden feeling of weakness
- Anxiety or an overwhelming sense of doom
- Collapse
- Loss of consciousness
If above symptoms occur in a mild non-life threatening form, 1-2 Benadryl may be taken to relieve symptoms. Remember; do not drive after taking Benadryl. Please notify our office if any symptoms occur after an allergy injection.
If life threatening symptoms do occur outside our office, the steps to follow are as listed below:
1. Use EpiPen
2. Call 911
3. Take two 25mg Benadryl tablets, or up 4 tsps of Liquid Benadryl (12.5mg/5cc)
4. If symptoms return and emergency personnel have not responded, the 2nd dose of epinephrine may be administered.
I understand and agree to carry an EpiPen on the day of my allergy injection for as long as I am on immunotherapy. 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.
| Date: _____________ | Patient Name: | ________________________________________ |
| ________________________________________ | ||
| Signature of Patient or Legally Responsible Party |
| Date: _____________ | Witness: | ________________________________________ |