Immunotherapy Pre-Injection Questionnaire

Please correct the errors described below.

This questionnaire is designed to optimize safety precautions already in place for your allergen immunotherapy injection (s) (allergy shot).

Please review and answer the following questions. The nursing staff will review your responses and notify your physician if they have any questions or concerns about whether you should receive your injection(s) today. If you are pregnant or have been diagnosed with a new medical condition, please notify the staff.

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

Your information will be encrypted.