My allergist or her staff has notified me that it is time for my serum to be remixed. Indications for remixing of serum are the following:
1) Concentrate serum and the subsequent dilutions need to be remixed every 6-13 months. It is time for my concentrate
2) My maintenance serum has expired or has run out of serum. Therefore, new maintenance serum needs tobe
I understand to notify the staff and/or physician of the Allergy and Asthma Center if there have been any changes to my
IUNDERSTAND THAT I AM NOT TO TAKE ANY BETA-BLOCKERS WHILE ON ALLERGY SHOTS.
I understand to notify the staff and/or physician if I have any reactions to my allergy shots that can include itchiness, hives, rash, wheezing, increased runny nose and/or throat tightness.
I understand that it can take up to 7-14 days from the date on this form for the remixing to occur. There may be an additional delay if mixing is to be done around the time of a national holiday.
I understand that my insurance company will be billed for the remixing procedure (CPT code 95165 The number of units billed varies upon the doses being mixed. If my insurance company does not cover the charges, I understand that I will be financially responsible for the remixing charges.