Allergy Immunotherapy Consent Form

I,   First Name   Last Name, acknowledge and hereby declare that I have been recommended an allergy immunotherapy treatment. In giving this consent, understand and acknowledge the following:

1. I understand that allergy immunotherapy is the process by which it intends to make the hypersensitivity or allergic reaction of the patient to a specific allergen such as dust, pollens, mold spores, dust mite) be less sensitive.
2. I understand that allergy immunotherapy does not take the place of avoidance of allergens to which I am known to be sensitized (allergic) and that the overall effectiveness of this injection treatment program also depends on my compliance with recommendations with respect to environmental controls, dietary restrictions, and use of medications.
3. I understand that the goal of this allergy immunotherapy is to reduce the sensitivity of allergic sensitivity. The improvement is a gradual process that takes up to one year or more. In best situations, it may completely eliminate the sensitivity but this does not apply to every individual. However, there is no guarantee that this therapy will, in fact, result in a cure or resolution of my symptoms.
4. I understand that periodic assessments shall be made that may take from three to five years. During this period, I shall make myself available for the physician to determine if the therapy should be continued, ceased, or modified.
5. I understand that it shall be my responsibility to check whether my insurance company covers allergy immunotherapy treatments or any components of such treatment before I sign to this consent.
6. I understand that although I am receiving allergy immunotherapy treatment, it does not mean that the treatment itself will not cause an allergic reaction. It is not strange for swelling or itching in cases of injections. I understand that other reactions may occur such as fainting, itching, hives, shortness of breath, or tightness in the throat or chest might occur. Due to the foregoing, I understand the possibility of life-threatening reactions from the treatment for which may occur such as anaphylaxis, shock which may result in death.
7. I understand that I should avoid strenuous exercise for two hours after my allergy injection therapy.
8. I understand that injections shall only be administered in a medical facility and by a trained medical person under the supervision of a physician. Should I undergo this procedure, I am required to be observed for at least 30 minutes.
9. I also understand that I must report to the Clinic as early as possible any problems that I might notice resulting from the treatment.

Consent to Use Medical Data

I give my consent to use my medical information for research and education   I give my consent for my photos to be taken   I give my consent for my photos to be disclosed for purposes of research and education    

Acknowledgement of Patient

By signing this form, I declare that I have read the information above or the information above has been read to me. I acknowledge that I have understood the same. I have had the opportunity to ask questions and all by which were answered to me to my satisfaction.

I hereby authorize the Clinic to administer treatment and I agree to release, waive, and hold harmless the Clinic from any claims, suit, or damages resulting in any complication which might arise in the course of, or after treatment, which may be a result from the said treatment.

Signature of Patient:   Signature   
Date Signed:   Date   

If Patient is incapable of giving consent by reason of age or mental capacity:

Name of Parent/Guardian: First Name   Last Name   
Signature of Parent/Guardian: Signature   
Date Signed: Date signed