Asthma & Allergic Disease Center
Livonia, MI
CONSENT TO RECEIVE IMMUNOTHERAPY
Instructions For Patients Receiving Immunotherapy
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Immunotherapy, hyposensitization, or allergy injections should be
administered at a medical facility with a medical physician present since
occasional reactions may require immediate therapy. These reactions may
consist of any or all the following symptoms: itchy eyes, nose, or throat; nasal
congestion; runny nose; tightness in the throat or chest; coughing; increased
wheezing; lightheadedness; faintness; nausea and vomiting; hives; generalized
itching; and shock, the last under extreme conditions. Reactions, even though
unusual, can be serious but rarely fatal.
Allergy shots should never be given at home.
You are required to wait in the medical facility in which you receive the
injections for a minimum of 20 minutes after each injection in case you
should experience an allergic reaction (you may not stand outside the
building or sit in your car). The allergy shot technician will check you
before you can leave. If you leave the allergy clinic before the 20 minutes has
elapsed, a warning will be given at your next visit. After two episodes of
leaving early, you will no longer be permitted to receive allergy shots at the
allergy clinic.
You must keep your scheduled follow-up clinic appointments. At a
minimum, you should be seen in the allergy clinic with each increase in
concentration or maintenance refill.
New vials should be ordered 2 weeks in advance of needing them. You will
need to receive the first dose from any new vial in the allergy clinic. This is
because there may be differences in the allergen content of the new vial and
therefore an increased risk of a shot reaction.
You should report recent or current illness before allergy shots are given.
Allergy shots may not be given if you are ill.
Except under very unusual circumstances, allergy shots should not be given if
you are taking a Beta-blocker agent. Patients taking B-adrenergic blocking
agents may be at increased risk when receiving allergen immunotherapy
because B-receptor blockade can make treatment of anaphylaxis more
difficult. Therefore, B-adrenergic blocking agents are relative
contraindications for immunotherapy. You must inform the allergy shot staff
if you have been started on a Beta-blocking agent.
Consent for treatment
I do hereby give consent for ________________________________ to be given
allergy shots over an extended period of time and at specified intervals as prescribed
by a member of the allergy clinic. I have read the above allergy shot rules and agree
to follow them. I also understand the risks that may be involved in receiving allergy
shots. I have been given the opportunity to ask any and all questions that I may have
and am satisfied that they have been fully answered.
I consent and authorize the treatment of any reactions that may occur as a result of an
allergy shot.
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Printed name of allergy shot patient
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Medical Record Number
_____________________________
Signature (allergy shot patient)
__________________
Date
_____________________________
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Signature (Authorized Consenting Party/Relationship) Date
I certify that I was present and heard the oral presentation to the patient and/or
authorized consenting party of the information contained in this consent and that it
appeared to me that the signee understood the nature, risks and benefits of the
proposed treatment and that I witnessed the above signature to this authorization.
_____________________________
Signature (Witness)
__________________
Date