You have completed the training for at-home administration of sublingual immunotherapy and you know how to recognize and manage potential problems that may arise during this treatment, such as local and systemic (anaphylactic) reactions.
Upon the completion of your sublingual immunotherapy training, please review the following statements for accuracy.
- I have completed the sublingual immunotherapy informed consent document given to me by the staff at CornerStone Ear, Nose & Throat, and have had an opportunity to ask questions.
- All of my questions were answered to my understanding and satisfaction.
- I understand the dosing schedule and dosing guidelines for my treatment, during both the build-up and maintenance phases, as well as the appropriate adjustments in dosing based on treatment intervals, previous adverse reactions, current acute illnesses, and vial expiration dates.
- All documentation requirements were discussed with me, including a review of all the forms that must be returned to the office.
- I understand that I must inform CornerStone Ear, Nose & Throat if any problems, changes, or questions arise regarding my allergy treatment, including payment plan for allergy drops, the ability to continue with the planned treatment, etc.
- I will be cooperative with requests from the doctors and staff at CornerStone Ear, Nose & Throat regarding adhering to dosing schedules, and scheduling yearly follow-up visits with my CornerStone Ear, Nose & Throat physician. I understand that if I do not comply with these regulations, the physicians of CornerStone Ear, Nose & Throat may discontinue my sublingual immunotherapy.
- I understand that I have been given an epinephrine auto-injector (EAI) prescription and that I am expected to keep both the EAI and an antihistamine available at the time of treatment.
- I understand that I cannot take beta-blockers while receiving allergy immunotherapy and have been provided with a list of these medications as a reference. I also understand that I am responsible for notifying CornerStone Ear, Nose & Throat if I am taking these medications.
- I understand that I need to notify CornerStone Ear, Nose & Throat if I am diagnosed with any new medical conditions, if there are any changes in medications that I am taking, or if I become pregnant.
- If you have any questions or concerns, please discuss them with our doctors or staff before proceeding.