Consent to Begin Sublingual Immunotherapy (SLIT)

AAWM agrees to prepare the allergy extract on my behalf.

Extract is billed at the time it is prepared.

SLIT is not currently a covered benefit under any insurance plans, and therefore, there are no CPT billing codes. I understand that I am responsible for cash payment to AAWM for the full cost of this service.

Sublingual Immunotherapy Cost
The number of allergy extract treatment vials a patient needs is based on skin test results, determining whether one, two or three treatment vials are required.

• Allergy extract starter sets for SLIT consist of three (3) vials of increasing strengths. The cost of each starter set is $70.
• Upon completion of the starter set(s), one new vial per starter set is prepared at the cost of $70 vial.
• SLIT is administered daily, and refills are required approximately every 6-8 weeks. New extract will be made at my request upon completion of my current vial(s)

Any outstanding balance must be paid before new extract can be prepared.

Extract is made specifically for the individual patient. In the event that the extract is prepared and not used, I am still responsible for any outstanding balance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.