Pre-Vial Paperwork

Allergen Immunology Questionnaire

FOR MEDICAL STAFF: Date of skin test at this office: ______________________________

Since your last visit, complete the following using a scale of 1 to 5 with 1 being zero symptoms and 5 stating you still have maximal symptoms. Some questions require a yes or no answer

1 = improved, no symptoms; never

2 = minimal symptoms; at times

3 = moderate symptoms; 50% of the time

4 = approximately 75% of the time still have symptoms

5 = no improvement in symptoms; always have symptoms

Immunotherapy Patient Consent Form

Immunotherapy, hyposensitization, or allergy injections should be administered at a medical facility with a medical physician present since occasional reactions may require immediate therapy. These reactions may consist of any or all the following symptoms: itchy eyes, nose, or throat; nasal congestion; runny nose; tightness in the throat or chest; coughing; increased wheezing; lightheadedness; faintness; nausea and vomiting; hives; generalized itching; and shock, the last under extreme conditions. Reactions, even though unusual, can be serious and rarely, fatal. You are required to wait in the medical facility in which you receive the injections for thirty (30) minutes after each injection. If the patient is 17 years of age or younger, a parent or legal guardian must be present during the waiting period. I verify that I (or patient) am not taking beta blocker medications or that if I am, I have discussed the risks/benefits of doing so with my physician (see information sheet).

I have read (if new patient) or re-read (if established patient) the patient information sheet on immunotherapy and understand it. The opportunity has been provided for me to ask questions regarding the potential side effects of immunotherapy 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 against such reactions. I also agree that if I have an allergic reaction to the injections, the physician-in-charge and medical staff have permission to treat said reaction.

Under certain circumstances, the code 99211 is charged, i.e., if the nurse must interrupt patient care in order for the physician to adjust a dose or medication, if you are late receiving your injections, have a medication change, asthma symptoms, vitals or any peak flow changes

You will be assessed a fee if the physician must adjust dosing due to the time required to review your records.

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. If my appointment is not kept, my insurance will not be billed and I will be responsible for the vaccine costs. Vaccines may be prepared 48 hours after your appointment is made. I agree to obtain a referral, if needed, from my insurance plan.