Aeris Medical Allergy Shot Consent Form

Allergy Shot Consent Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you allergic to any medications?*

yesno
If yes, list medications
When did you last have an allergy shot?*
WOMEN: are you pregnant or breastfeeding?*

yesnodoes not apply
Do you have any of the following?*

Healing broken bonesOsteoporosisDiabetesHigh blood pressureSeizuresBrain injury or diseasemuscle related diseasehistory of faintingdoes not apply
Have you eaten today?*

yesno
The injection contains a small amount of steroids and may in rare cases cause a dimple to form at injection site.*

I understand and agree to injection
This injection is known to cause dizziness, light headedness and/or fainting. If you feel any of these, please inform us immediately.*

I understand and agree
Your Signature*
If you have any questions or concerns please call our office at 505-433-4043

In case of emergency contact your provider.

Amanda Armijo- Amanda@aerismedical.info

Tyler Owens PA-C-Tyler@halomedspaabq.com

Lawrence Armijo-Lawrence@aerismedical.info

Medical Director: Tyler Owens
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