Health
Services
Dear Incoming Freshman Student,
Allergy Immunotherapy Program Requirements and Responsibilities
Congratulations on your acceptance to Marist College!
Health Services, located in Room 350 of the Student Center, provides care to all full-time undergraduate
If Marist
you have
been receiving allergy immunotherapy (“allergy shots”) from your allergist at
students.
The continue
office is staffed
by physicians,
practitioners,
physician assistants, nurses and clerical staff.
home, you can
treatment
at Maristnurse
Health
Services (MHS).
After hours or in emergencies, students are referred to the Emergency Department of Saint Francis Hospital,
which isimmunotherapy
across the street is
fromgiven
the Marist
College campus.
Allergy
by appointment
during Fall and Spring academic
semesters, Monday through Fridays, during daytime hours, when a physician or nurse
Enclosed are
Marist Health
Services
forms
which must
be completed
signed.serum.
You should schedule a visit
practitioner
is present.
MHS
provides
refrigerated
storage
for yourand
antigen
with your primary care provider so that all forms can be received at Marist College as soon as possible after
July 30
for will
incoming
Fall students.
(If you are Bursar
unable toAccount
scheduleinyour
exam in time for
Aenrollment,
charge forbyeach
visit
be posted
to the student’s
thephysical
Business
the
deadline,
please
submit
all
other
forms
and
note
“physical
exam
to
follow”
with
the
date.
If
you have had a
Office that will be payable at the end of each semester.
complete physical since September 2009 that is documented on a similar form, you may submit it for review.)
For 1 injection, the charge is $10
2, injections,
the charge
If you For
choose,
you may include
page is
10,$15
“Consent to discuss medical information for students 18 and older,” so
For
3
or
more
injections,
the
charge
is with
$20 your parents or guardians.
staff can discuss confidential health information
Marist College varsity athletes and students who may want to try out for a varsity team should not complete this
Initial
appointment
packet
of forms. They must complete and send “Incoming Athlete Medical Forms” to the Marist College Office
of Athletic Training by July 15 for Fall semester. A copy of all forms must also be sent to the Office of Health
AtServices.
your first Incoming
appointment,
the
MaristForms
Health
Services
staff will evaluate your health
Athlete
Medical
are
available(MHS)
at www.marist.edu/healthservices/healthforms.
history and review your antigen immunotherapy program prior to assuming responsibility
for providing this service to you. You must have started your allergy immunotherapy
We strongly recommend that you keep a copy of all health forms for your own reference. It takes our staff most
in your allergist’s office.
of the summer to process and review the many hundreds of incoming forms. Please do not phone to see if
your forms have arrived. If you need to know that your forms were received, please send them “return
receipt requested” via US mail and you will receive confirmation by return mail.
Allergy Serum
willbe
not
be allowed
to move
into campus housing
registerschedule
for classes
AllStudents
vials must
properly
labeled
and accompanied
by your or
injection
andunless proof of
immunization
has been Required
received (see
page 2). includes:
allergist’s
instructions.
information
We
forward
 look
Your
nameto working with you to ensure a healthy Marist experience.
 Contents of each vial of serum
 Dilution of each serum
 Dosage schedule
 Adjustments based on type of reaction or longer interval between injections
Mary L. Dunne, MD
 Signature of allergist and printed name and address
Medical Director
 Allergist’s office telephone number and office hours
Sincerely,
Enc:
page 2
Medical History / Emergency Contact / Health Insurance information
page 6
page 7
page 8
page 9
page 10
Physical Examination Form - to be completed by Health Care Provider
Copy of front of insurance card
Copy of back of insurance card
Medical Authorization and Consent form
Consent to discuss medical information (for students over 18)
page
3
Measles,to
Mumps,
andthat
Rubella
(MMR)
Vaccinationis
Information
It is your
responsibility
assure
this
information
provided at the time of the
page 4
Mandatory Meningitis Information
appointment.
will Mandatory
not be given
unless
the information is complete.
page 5 Injections
Marist College
Immunization
Information
Office of Health Services
Marist College, Poughkeepsie, NY 12601-1387
845-575-3270 - health.services@Marist.edu
1
Health
Services
Important Safety Concerns
Before you receive your injection, inform the nurse of your recent medical history,
including any medications that you are taking. Certain prescription medications used to
treat eye problems, headaches, or high blood pressure may contain beta blockers which
can increase the risk of serious reactions to allergy injections. If you have recently been
ill, you must inform the nurse of any symptoms.
You will be required to wait 30 minutes after receiving your injection(s), so plan
your appointment accordingly.
Life threatening reactions can occur even in individuals who have been receiving allergy
injections for a long time.
Failure to comply with the wait requirement will result in
allergy injection services being discontinued.
During the waiting period after the injection, notify the nurse immediately if you experience
any of the following:











Anxiety (“feeling strange”)
Excessive coughing
Excessive sneezing
Facial swelling
Flushing
Hives
Itching
Runny nose
Shortness of breath
Wheezing
Any other symptom that occurs following your shot that concerns you
You should also call the nurse (ext3270) to report any localized reaction that occurs after
you leave Health Services.
You will need to be prepared to use emergency medications if sudden severe symptoms
occur after leaving Health Services. Students will be required to purchase an EpiPen
Auto-Injector and a bottle of children’s liquid Benadryl (diphenhydramine) and learn about
appropriate self-medication. You will need to carry these medications on the day of your
injection. Injections will not be given unless you have these medications with you.
Compliance with treatment
It is the responsibility of the student to pick up the antigens and a copy of the treatment
program during semester breaks and at the end of the academic year, and to bring these
materials upon return to campus. Vials in transit should be handled according to the
student’s allergist’s instructions.
It is the student’s responsibility to arrange continuation of allergy immunotherapy while
away from the campus.
Students will be charged for any appointment not cancelled or rescheduled 24 hours in
advance. Students who miss an appointment will be given a warning. Students who miss
two appointments will not be allowed to continue allergy immunotherapy at MHS.
2
Health
Services
Consent Form
1. I have read the Marist Health Services (MHS) Antigen Program Requirements and
Responsibilities and I have had the opportunity to ask questions and receive
answers regarding the information contained in it.
2. I agree to comply with the requirements and understand that failure to do so may
result in my not being able to continue receiving allergy injections at MHS.
3. I am aware that local reactions are not uncommon. I will monitor the size of the
reactions and the length of time they last and inform the MHS staff.
4. I am aware that generalized reactions occur less commonly, and may include
symptoms of itching of the skin; sudden itching of the nose, mouth, ears, and
throat; hives, wheezing, coughing, tightness of the chest, nasal congestion and
sneezing. I am aware that rare serious reactions may result in significant
respiratory difficulty or anaphylactic shock, which may be life-threatening.
5. I understand that a serious reaction usually occurs within 30 minutes after an
injection. I agree to remain in MHS for 30 minutes after my injection(s) and to
immediately report any symptoms to the MHS staff.
6. I understand that in the event of a serious reaction, emergency treatment will be
initiated and Fairview Fire District Emergency Medical Services will be contacted
for transportation to Saint Francis Hospital Emergency Department.
7. I agree to purchase an EpiPen Auto-Injector and a bottle of children’s liquid
Benadryl for my own emergency use. I agree to carry these medications with me
on the day of my allergy injection(s).
8. I have had the opportunity to have all of my questions about allergy
immunotherapy answered to my satisfaction. I have been informed of the potential
risks and benefits of allergy immunotherapy.
9. I will not hold Marist Health Services responsible for any reactions I may develop
as a result of allergy injections.
__________________________________
Student signature
______________________________
Student name
_________________________________
Parental Authorization (for minor)
______________________________
Parent name
______________________________
MHS Staff Witness signature
______________________________
Witness name
3