I have the intent to begin allergy immunotherapy and consent to have my personalized allergy serum mixed. I understand that my serum may be mixed on a day that I am not present in the clinic. It has been explained to me that my insurance may be billed for this service, even if I later choose not to receive immunotherapy. I have had all of my questions answered by the allergy staff and fully understand my personal responsibility for this billing process. I understand that sublingual immunotherapy is a treatment that is not currently covered by insurance and that the monthly cost will be an out of the pocket expense. I have read and understood the above information completely. I understand that my personalized allergy serum will continue to be mixed every two to three months without prior notice unless I sign the form to stop treatment (Discontinuation of Immunotherapy).
Epinephrine Auto-Injector Training
I have watched the epinephrine auto-injector training video (EAI) in its entirety. I further have been taught how to use an EAI in case of an emergency. I understand how to use an EAI in case of anaphylaxis. I also understand that the EAI 2-Pak is to be kept together and not separated in case a second dose of epinephrine would be needed for treatment. I understand that an immediate evaluation at the emergency room is needed if epinephrine is administered. I also understand that CornerStone Ear, Nose, and Throat will need to be notified if the epinephrine is administered so that a refill for the EAI can be prescribed. I have had all of my questions regarding the use of an EAI and anaphylaxis answered to my satisfaction.