The purpose of this page is to ensure that your decision to have allergy testing and subsequent allergy treatment is made with the full knowledge of the possible risks of this medical care, and to ensure that you understand the purpose and benefits of allergy testing and allergy immunotherapy.
Allergy immunotherapy is effective for patients who suffer from severe allergies, as well as those who have found conventional oral and topical medical treatment to be ineffective in controlling their allergy symptoms. Allergy immunotherapy is up to 90% effective when the patient is compliant with the treatment plan. Approximately 10% of patients will not improve with allergy immunotherapy.
It is important to note that it takes 6 to 8 months for most patients to see results from allergy immunotherapy. It is typically necessary to also use allergy medication during the first 2 years of allergy immunotherapy. While attempts will be made to decrease the allergy medications that patients are taking as soon as possible, some patients will need to continue taking allergy medications. This is individual to each patient depending on his or her symptoms.
When beginning allergy immunotherapy, there are certain risks of reactions that the patient assumes, such as local skin reactions and/or generalized allergic reactions (anaplalaxis). Generalized allergic reactions (anaphylaxis) after skin testing and immunotherapy are rare, but can potentially be life-threatening, and may require immediate medical attention. The possible occurrence of these types of reactions should be noted by the patient before agreeing to proceed with testing or immunotherapy. There may be symptoms the patient experiences as a result of such a reaction, including, but not limited to: hives, shortness of breath, a sudden and potentially dangerous drop in blood pressure, and a rapid or weak pulse rate. A local reaction (at the site of skin testing or the injection site of allergy immunotherapy) may also occur and appear as skin redness, itching, or localized swelling. These symptoms may require immediate treatment, initiated in the office, and possibly continued in a hospital setting.
I have read the information above in this consent form and understand it. I hereby authorize the physicians and staff of CornerStone Ear, Nose & Throat to perform allergy testing and allergy immunotherapy. I understand the risks, expected benefits, alternative care options, and potential complications associated with immunotherapy and allergy testing. I wish to proceed with my allergy treatment. I have been informed regarding insurance coverage related to allergy immunotherapy at this time and I understand that I am responsible for notifying the office of any insurance changes. I agree to inform the office if I am diagnosed with any new medical conditions, if I become pregnant, or if there are any changes in medications that I am taking. I also agree to be compliant with the immunotherapy treatment plan proposed by my physician and understand that allergy immunotherapy is typically a 3-to-5-year treatment process.