Allergy Immunotherapy Release

Upon the completion of your immunotherapy training, please review the following statements for accuracy.  

  • I have received the folder of immunotherapy information 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 that before my injections are administered, I must inspect my vials to be certain that they are mine and are current, including the correct name, bottle number(s), birth date,  and vial expiration date.  
  • I understand the guidelines for assessing adverse reactions to immunotherapy injections and the proper actions to take if a reaction occurs. I understand it is my responsibility to inform the CornerStone Ear, Nose & Throat staff of any systemic reactions I may experience and that I will be required to come to the office to see a CornerStone Ear, Nose & Throat physician following such a reaction. 
  • I understand that I must inform CornerStone Ear, Nose & Throat if any problems, changes, or questions arise regarding my allergy treatment, including insurance coverage, 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 injection schedules, waiting for 30 minutes in the office following injections, 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 injections. 
  • I understand that I have been given a prescription for an epinephrine auto-injector (EAI) and that I am expected to bring the EAI with me to the office each time I receive an allergy injection, as well as to keep it readily available after leaving the office in case I develop symptoms of an allergic reaction. 
  • 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. Patient