I, the undersigned parent or legal guardian of the Patient stated here, a minor, do hereby authorize and the right to consent to allergy treatment away from ASCEND Pediatric Pulmonary PLLC. I agree that I have read this consent and I understand the consent and all questions have been answered.

I understand the unpredictable nature of allergies and related symptoms and that the clinic can’t guarantee any results. The clinic can’t guarantee any new allergies will not develop in the future. I’m aware of the risks with administering allergy injections. I assume all responsibility from unpredictable immune reactions. In this event I agree to seek immediate medical attention. I understand the use and instructions given to me.

I will follow all instructions given to me when administering injections. I will always have my EpiPen ready and available in case of anaphylaxis reaction. Anaphylactic symptoms may include, but are not limited to difficulty breathing, swallowing, hives, swelling around the mouth and eyes. If doing allergy injection at home, the clinic and its employees assume no responsibility for medical conditions requiring the attention of a medical doctor, or necessary adjustments to prescribed medications during or after the completion of treatments away from the clinic.

I fully understand the use and instructions given to me for Allergy Injections at Home Treatment and EpiPen. I will follow all the instructions given when administering allergy treatment at home.

I waive and release ASCEND Pediatric Pulmonary PLLC, its successors, owners, employees from any claims, lawsuits and damages that I may suffer as a result of allergy treatment at home.

 
By signing this form, I represent that I am the legal representative of the Patient identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Patient’s behalf with respect to this authorization form.