Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

MEMORANDUM FOR: Allergy Immunotherapy Patients
SUBJECT: Allergy Patient Consent / Instruction Sheet
1. As a service to our patients, the ________ clinic administers
Allergy Immunotherapy (AIT) for pollens, molds, and animal dander, and
stinging insects as directed by your Allergist.
2. An Allergy specialist must evaluate your medical condition,
prescribe a course of AIT, and supply the allergen extract vials. Your
first shot of any new prescription must be given at your Allergist's
office. The site for the first shot of a refill vial will be at your
Allergist’s discretion.
3. We will maintain your allergen vials in our medication
refrigerator. This will ensure your extract is maintained at the
proper conditions. All vials must be labeled with name, vial number or
v/v concentration, prescription number, contents, and expiration date
in accordance with ACAAI standards of care.
4. Before treatment begins, you will be required to have a completed
AIT patient questionnaire on file.
5. "Allergy shots" will be given in room _____, on weekdays from 9:00-
11:00 and 1:00-3:00 [modify times as appropriate]. A fully credentialed
health care provider and nurse must be present to administer your
allergy shots. Availability of Medical staff may be limited on rare
occasions due to other primary duties, and you may not be able to
receive your shot. A brief delay in receiving your AIT will not pose a
health risk, but may result in a subsequent dose adjustment.
6. You are receiving injections of the materials to which you are most
allergic. You may have very significant local or generalized reactions
that require prompt treatment.
7. Nearly all of the serious and rapidly progressive reactions begin
within 30 minutes after the shot.
8. We require a 30 minute waiting period after all allergy injections.
You must wait in _______ after your injections and be checked by a
staff member before leaving. If your schedule does not permit you to
wait the required 30 minutes, you will not be able to receive your shot
at that time.
9. Promptly inform the staff if you are having any significant
increase in itching, hay fever, asthma, hives, shortness of breath,
throat clearing, or other discomforts you did not arrive with.