Patient Information and Consent form on Immunotherapy ...

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Immunotherapy (allergy Shots) Name:____________________

Patient Information and Consent

DOB:_____________

Midwest Allergy, Asthma and Immunology



Definition: Immunotherapy, otherwise known as “allergy shots” or allergy vaccine, is prescribed for aeroallergen allergic patients who have symptoms inadequately controlled by environmental control measures and medications, or who wish to avoid or reduce long-term use of medications1; and for patients allergic to stinging insects (Hymenoptera).

Effectiveness: Immunotherapy works by attenuating the allergic response to aeroallergens (pollens, molds, animal dander, dust mites, etc.) and stinging insects. This “tolerance” is achieved over a period of months to years.

Schedule: The “build-up” phase lasts approximately 6-9 months, depending on your response, and consists of a weekly injection of a gradually increasing dosage. Some patients may require several injections at each visit. Once the “maintenance dose” (full strength vaccine) is achieved, injection intervals may gradually increase to once every 3-4 weeks for aeroallergens (4-8 weeks for stinging insects).

Duration of therapy: For best results, it is recommended that you continue allergy shots for at least 3-5 years. The decision to continue allergy shots for a longer period of time will be made by you and your physician based on several factors, including your current symptoms and overall response.

Safety: In general, allergy shots are safe. However, local and systemic reactions are possible. Local reactions occur at the injection site and can consist of itching, redness, or swelling. Our office should be notified if you have a reaction larger than 3 inches in diameter and/or if it lasts longer than 24 hours. Systemic reactions can consist of, but are not limited to itching, sneezing, coughing, wheezing, hives, or light-headedness. Rarely, such reactions can be life-threatening. Systemic reactions require immediate treatment with epinephrine. Most systemic reactions occur within 30 minutes after an injection.

Allergy shots should be given at a physician’s office equipped to treat systemic reactions. You are required to wait in the office for 30 minutes after your shot(s). You will be leaving against medical advice if you leave prior to 30 minutes.

Postpone your allergy shot(s) if you have a high fever or asthma symptoms (shortness of breath, wheezing, persistent cough, chest tightness).

I have read and understand the above patient information on immunotherapy. The opportunity has been provided to me to ask questions regarding possible reactions and 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. I agree to begin allergy shots for myself (or my child), and I also give permission for treatment of myself (or my child) if a reaction occurs. I will notify your office immediately if my (or my child’s) overall health changes, if I (or my child) am prescribed a beta-blocker medication (ocular or oral), or if I (or my child) become pregnant.

I acknowledge the fact with my signature that I am authorizing the office to bill for allergen vaccines, even if, for any reason, I decide not to initiate the allergen immunotherapy program after the vaccine has been made.

Patient’s signature: _____________________ Printed name: __________________ Date: ___________

Guardian’s signature: ___________________ Printed name: __________________ Date: ___________

Witness’ signature: _____________________ Printed name: __________________ Date: ___________

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