Allergy Immunotherapy Consent Form

Patient Name:

Date of Birth:

Date:

Purpose of Allergy Immunotherapy

Possible Risks and Side Effects

Possible Benefits

Alternatives

Consent Statements

I have been informed about the purpose, procedure, risks, benefits, and alternatives of allergy immunotherapy.
I have had the opportunity to ask questions and all of my questions have been answered.
I understand that I can withdraw my consent and discontinue treatment at any time.

Additional Comments or Questions:

Patient/Guardian Signature:

Date:

Provider Signature:

Date: