Edward J. Sarti, MD
Michael J. Katz, MD
Sherif Hassan, MD
Michael A Zozzaro, MD
Cyrus Nozad, MD
Otolaryngology, Head & Neck Surgery
Otolaryngology, Head & Neck Surgery
Otolaryngology, Head & Neck Surgery
Otolaryngology, Head & Neck Surgery
Allergy & Immunology
www.NJFamilyENT.com
47 Orient Way
Rutherford, NJ 07070
201-935-5508
6 Brighton Road
Clifton, NJ 07012
973-470-0282
1265 Paterson Plank Road
Secaucus, NJ 07094
201-864-4419
Immunotherapy Patient Consent
Name:
MRN:
Purpose and Efficacy:
The purpose of immunotherapy (allergy injections) is to decrease your sensitivity to allergy causing substances, so that exposure to
the offending allergen (pollen, mold, mites, animal danders, stinging insects, etc.) will result in fewer and less severe symptoms.
Improvement in your symptoms will not be immediate. It usually requires 3-6 months before any relief of allergy symptoms are noted
and it may take 12-24 months for full benefits to be evident. About 80% or greater of allergic patients on immunotherapy note
significant improvement of their symptoms. Allergy injections are begun at a very low dose. This dose is gradually increased
approximately once per week until maintenance doses are reached. This takes approximately 9-12 months to achieve, but maybe
longer. After the maintenance dose is reached, injections can be given every 3-4 weeks. It is recommended that patients on
immunotherapy continue treatment for 3-5 years as this has been shown to cause longer term remission of symptoms. Of note, your
dosing schedule may vary for various reasons e.g. missed doses.
Local Reactions:
Most patients receiving immunotherapy will sometimes have small areas of redness, swelling, and itch at the site of injection that
produce little discomfort and are of no concern. These are to be distinguished from large, local reactions, 1 to 1.5 inches or greater in
diameter which may cause considerable discomfort and persist for 24 hours or longer. Such reactions may be associated with either a
systemic reaction or create concern that a further increase in dose may cause a systemic reaction (see below). After a large local
reaction, the dose will be reduced to one that does not produce a significant degree of swelling. It is the responsibility of the patient
and/or parent/guardian to inform the physician of any local reactions. In addition we ask that you refrain from strenuous exercise for 30
minutes before and 2 hours after the injection.
Systemic reactions:
The manifestations of systemic reactions range in severity and may include any of the following: nasal congestion, itchy eyes or throat,
tightness in the throat, hives, swelling, flushing, wheezing, chest tightness, cough, lightheadedness, faintness, nausea, vomiting,
diarrhea, headache, chills and stomach pain. Anaphylactic shock is the rarest complication, but is a serious event characterized by
acute asthma, vascular collapse (low blood pressure) and potentially death. This reaction is extremely rare and usually occurs within
minutes of the injection. For this reason it is recommended by the American Academy of Allergy and Immunology that there is a
waiting period of at least 30 minutes after allergy injection in the doctor’s office. Some reactions may be delayed up to 6 hours after the
injection. In the event of a severe reaction, like the ones described above, one should proceed immediately to an emergency treatment
center/call EMS and call the physician even if the reaction stopped spontaneously. In addition an emergency care plan will be
reviewed with you. It is important to write down on which arm the swelling occurred and that this information be conveyed to the doctor
before your next injection.
Pregnancy:
Females of childbearing potential: If you become pregnant while on immunotherapy, notify the office staff immediately, so your
physician can determine an appropriate dosage schedule for the injections during pregnancy. Immunotherapy doses will not be
advanced during pregnancy, but may be maintained at a constant level.
During the course of your treatment it is mandatory that you inform the doctor of any changes in medications or health status.
Medications such as beta blockers may increase your risk of systemic reactions.
I have read (if new patient) or reread (if established patient) the patient information sheet on immunotherapy and understand it. An
opportunity has been provided for me to ask questions regarding the potential side effects of immunotherapy and all my questions
have been answered to my satisfaction. I understand that every precaution consistent with the best medical practice will be carried
out to protect me against such reactions. My insurance will be billed for the allergy immunotherapy vaccine and I understand
that I will be financially responsible for any balance remaining.
Patient (or parent if patient is a minor)
Date
Witness
Date