I consent to receiving my allergy immunotherapy injections at a physician-supervised medical facility outside of
I understand that I am to wait for at least 30 minutes after each allergy injection. I understand that the outside medical facility where I receive my allergy injections is responsible for managing any adverse reaction that I may have to my allergy injection, including hives, difficulty breathing, and anaphylaxis.
I understand that if I am having a fever, rash, wheezing or other respiratory symptoms, I am to notify my supervising physician and will not receive my allergy injection at that time. I understand that I am to bring the allergy serum to the outside medical facility each time I am scheduled to receive an injection.
At other times, the allergy serum is to be refrigerated. Dr. Wasan is responsible for giving the dosage schedule orders to the outside medical facility.
I was prescribed an Epi-Pen twin pack at my initial office visit at Dr. Wasan's office. I have filled the prescription and understand the indications and instructions on the use of the Epi-Pen.
I understand that I am to receive my first allergy injection from each new vial at Dr. Wasan's office. I have read the above consent form and all of my questions have been answered appropriately.