OFFICE:
PHONE:
PATIENT NAME:
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DOB:
Allergic Disease Associates, P.C.
Specializing in Allergy, Asthma, Clinical Immunology & Non Surgical Sinus Disorders
INFORMATION AND INFORMED CONSENT
FOR ALLERGY IMMUNOTHERAPY (ALLERGY SHOTS)
PURPOSE AND INDICATIONS:
Immunotherapy (allergy shot) injections are administered only to allergic patients who have moderate to severe
symptoms of upper respiratory allergies, allergic asthma, or insect sting reactions not adequately controlled by
environmental avoidance or medications.
HOW DO ALLERGY SHOTS WORK?
Your injections will contain the allergens to which you are sensitive which might include pollen, dust mites, cat
dander, mold, insect venom etc. Unlike medications, allergy injections do not directly suppress symptoms, instead they
initiate processes that seem to "turn off" the abnormal immune reaction that we term "allergy." The result is that you
become less sensitive to the allergen(s) injected and need fewer medications. Most patients benefit from such therapy. It
usually takes 1-2 years of therapy to achieve the desired results although some patients show benefit early. If no
response is seen within 1-2 years of injections, therapy is discontinued.
HOW LONG DO I RECEIVE SHOTS?
A course of allergy injections often lasts 3-6 years. Shots begin with a very low dose, then are built up gradually
on a regular basis (usually 1-2 times per week) until a therapeutic or "maintenance dose" is achieved. The highest
tolerated maintenance doses are given every 2-4 weeks with a goal of ultimately achieving injections every 3-4 weeks. It is
important to maintain shots at the proper time interval. Missing shots for a short vacation or for some other acute medical
problem is acceptable. You will be re-evaluated occasionally with skin testing while on allergy injections and subsequent
changes in the extract or schedule may be necessary to obtain the best results. We will usually consider discontinuing
injections when you have minimum symptoms and have a normal or near-normal exam for at least one year. Most patients
will continue to do well after stopping shots, and some will have a slight increase in symptoms controllable with
medications. A small number of patients, however, will require resumption of allergy injections. Other guidelines (which
The Asthma Center specialists will review with you) are used for stopping shots when used for asthma and insect sting
reaction.
REACTIONS TO IMMUNOTHERAPY:
Fatalities associated with allergy immunotherapy have been reported and are extremely rare. However, most
reactions if they occur at all are not life threatening and respond to treatment. Allergy injections should only be given under
the direct supervision of a physician so that in the event of a reaction it can be monitored and treated. While most patients
do not normally experience reactions other than minor reactions, it is important for you to know about potential reactions.
The types of reactions are outlined below.
Local reactions (swelling, itching, heat, redness or tenderness) at the site of injection may occur in most patients
receiving shots. These local reactions usually resolve within 24 hours or less. Local reactions may occur immediately or
several hours after your injection.
Systemic reactions may consist of any or all of the following symptoms: itchy eyes, nose or throat; runny nose;
nasal congestion; sneezing; tightness in the throat or chest; coughing or wheezing; swelling of tissue around eyes, tongue,
throat or hives beyond injection site. Also, some may experience lightheadedness, faintness, nausea, vomiting, diarrhea,
stomach or uterine (menstrual-type) cramps, drop in blood pressure and in some extreme conditions, loss of
consciousness reactions and/or heart rhythm problems which may be serious but rarely fatal.
Large local reactions in general and systemic reactions may occur in 1-5% of the patients and usually occur during
the build-up phase although they can occur at any time during the course of treatment. These reactions necessitate a
dosage adjustment. The overwhelming majority of these reactions occur within 30 minutes of the injection and should be
reported immediately to the nurse or physician so that they may be reversed with medications while in the office.
IT IS THE RESPONSIBILITY OF EACH PATIENT TO REMAIN IN THE OFFICE FOR 30 MINUTES
AFTER EACH INJECTION TO MAKE CERTAIN THAT YOU DO NOT EXPERIENCE AN ALLERGIC
REACTION. DISREGARD OF THIS WAITING PERIOD FOR PATIENT SAFETY MAY BE CAUSE
TO DISCONTINUE IMMUNOTHERAPY. If after leaving the office you experience significant swelling or
tenderness in your arm, please tell the nurse prior to your next injection. In addition, if after leaving the office you
experience a generalized reaction, please immediately return to the office during office hours or proceed to the nearest
emergency room. Patients who cannot keep a regular allergy injection schedule are discouraged from continuing
injections since an erratic injection schedule is associated with a higher incidence of reactions.
PATIENT INITIALS
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PRECAUTIONS:
Patients will not receive shots if they have a fever or a flare of their asthma or hives or severe hayfever. Do not exercise
for 2 hours following your injections. Avoid alcohol ingestion for at least 4 hours before and 4 hours after your shot.
ON THE DAY OF YOUR SHOT, YOU SHOULD HAVE INJECTABLE EPINEPHRINE (TWINJECT
OR EPIPEN) IMMEDIATELY AVAILABLE TO YOU. YOU CANNOT TAKE BETA-BLOCKERS (used
to treat palpitations, high blood pressure, migraines, glaucoma) while on allergy injections (See List Below). Please notify
the administering nursing staff of any change in your medications. Women who become pregnant may continue allergy
injections but may have their dose reduced during the pregnancy. Women who are trying to conceive should inform The
Asthma Center doctor immediately. DURING YOUR ALLERGY INJECTION PROGRAM, YOU WILL
NEED TO KEEP REGULARLY SCHEDULED DOCTOR APPOINTMENTS. AT A MINIMUM, YOU
SHOULD BE SEEN EVERY 6 MONTHS OR YOUR EXTRACT WILL NOT BE RENEWED.
ALLERGY EXTRACT ADMINISTERED OUTSIDE OUR OFFICE:
Allergy injections should be given at a medical facility with a physician present.
HOME TREATMENT OR
TREATMENT BY A NON-PHYSICIAN HEALTH PROFESSIONAL WITHOUT DIRECT PHYSICIAN
SUPERVISION IS NOT PERMITTED BECAUSE IT PUTS THE PATIENT AT UNACCEPTABLE
RISK. Unpredictable allergic reactions do occur which require immediate medical attention. You should inquire that your
doctor's office is fully equipped with epinephrine, other medications and appropriate equipment as needed to treat allergic
reactions. In addition, we recommend the following procedures:
1. Review the allergy injection schedule with us before leaving our office.
2. At the primary care physician's office, review the dose administered each time and check that you are receiving the
schedule given by our office. Any changes in the schedule should be explained.
3. Discuss any reactions to your previous injection before receiving your next injection.
4. Follow precautions listed above.
5. Bring your allergy extract, injection schedule, and appropriate referral (when required) to our office during
your next appointment when your extract needs to be renewed.
6. Your allergy extract should be stored in the refrigerator (Do Not Freeze). Extreme temperatures alter potency of
extracts.
7. Do not continue using extract after the expiration date on the label.
I have read or have had read to me this patient information sheet on immunotherapy and understand it. I have read the
above allergy shot rules and agree to follow them. I agree that I will not attempt to administer my extract to myself nor will I
permit anyone who is not a licensed physician or under the direct supervision of a licensed physician to administer these
extracts. The opportunity has been provided to me to ask questions regarding the potential side effects of allergy
injections as well as potential benefits. These 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 or my child against such reactions in
this office. I have been given the opportunity to ask any questions I may have and I am satisfied that my questions have
been fully answered. Medication alternatives to immunotherapy include antihistamines, decongestants, topical prescription
nasal sprays, and/or anti-asthma medications. While some people are controlled with these medications, many patients
benefit and prefer to be treated with a course of immunotherapy injections to control their symptoms. I consent to
treatment for adverse effects as a result of allergy immunotherapy treatment that occur.
I understand that The Asthma Center allergist has prescribed customized allergy extract(s) which will be formulated
exclusively for me or my child. I understand that Allergic Disease Associates (The Asthma Center) will bill my insurance in
a timely manner in order to pay for my allergy extract(s) (pollens, molds, mite, dander, and/or insect venom(s)). I
understand that if I am not covered by insurance, I will need to purchase my extract(s) before I can receive any injection(s)
with the extract(s).
Patient or Parent if Patient is a Minor
Date
Witness
Date
BETA BLOCKER LIST
BRAND NAMES
AKBeta (eye drop)
Betagan (eye drop)
Betagan Liquifilm (eye
drop)
Betapace, Betapace AF
Betaxon (eye drop)
Betimol (eye drop)
Betoptic (eye drop)
Betoptic S (eye drop)
Blocadren
Brevibloc
Cartrol
Coreg
Corgard
Corzide
Cosopt (eye drop)
Inderal, Inderal LA
Inderide, Inderide LA
Kerlone
Levatol
Lopressor, Lopressor HCT
Normodyne
Normozide
Ocupress (eye drop)
OptiPranolol (eye drop)
Sectral
Tenoretic
Tenormin
Timolide
Timoptic (eye drop)
Timoptic-XE (eye drop)
Toprol XL
Trandate
Trusopt (eye drop)
Visken
Zebeta
Ziac
GENERIC NAMES
Abetalol
Acebutolol
Atenolol
Betaxolol
Bisoprolol
Carteolol
Carvedilol
Dorzolamide
Esmolol
Labetalol
Levobetaxolol
Levobunolol
Metipranolol
Metoprolol
Nadolol
Penbutolol
Pindolol
Propranolol
Sotalol
Timolol