MEMORANDUM FOR ALLERGY PATIENTS
Patients receiving injections of an allergy extract are at risk for a variety of potential complications including local reactions, exacerbations of existing asthma, serum sickness and potentially life-threatening anaphylaxis. The medical personnel supervising your care at this facility are responsible for providing emergency medical care to you in the event of an adverse reaction to the allergy serum.
It is therefore essential, for your protection, that this office have certain basic information on you which has been requested in the enclosed package. In addition, you need to be aware of the limitations on our services. Your private physician must provide clear and specific guidelines regarding your immunotherapy program in order for us to give your allergy injections.
Anyone who is eligible to receive their allergy injections in the Capitol Health Unit, must have the enclosed forms completed and returned to this office prior to initiation of the therapy. If you develop any problems with the injections and require referral back to your primary physician, a progress note (including assessment/recommendations) must be returned to this office prior to resuming your allergy injection. You are urged to see your primary care physician at least once a year. You are also responsible for advising this office (in writing) in the event of one or more of the following: (1) any changes, (2) interruptions in your therapy, (3) other medical problems occur that may complicate your ongoing therapy, (4) new medications are prescribed, or (5) you develop any new drug allergies.
We are pleased that we are able to provide this service; however, please ensure that you comply with our Quality Assurance rules and regulations governing this program.
Sincerely,
John F. Eisold, M.D., F.A.C.P.
JFE:rjb:bwc
Enclosures:
(1) Consent Form