Epinephrine Auto-Injector (EpiPen) Consent Form

Patient Name: Date of Birth: Allergies (if known):

Consent

I acknowledge that I have been informed about the use and administration of the Epinephrine Auto-Injector (EpiPen) for the emergency treatment of severe allergic reactions (anaphylaxis).

• I understand the indications for use.
• I have been instructed in proper administration technique.
• I understand the importance of seeking immediate medical attention after use.
• I consent to the administration of epinephrine in the event of anaphylaxis.

Additional Instructions or Notes: