RELEASE OF ANTIGEN CONSENT FORM

Patient Name: ________________________________________ Date of Birth: ________________

I request that my own or my child’s antigen prepared by the Allergy and Asthma Medical Group, Inc., 
be administered in the office of and under the supervision of_______________________________.

___________________		____________________________________________________
Date					Signature of Patient or Parent

The physician supervising the allergy injections understands his or her medical responsibilities. These responsibilities include assessing the patient prior to giving injections and treatment of untoward local and/or systemic reactions. Systemic reactions can progress to anaphylactic shock and involve the respiratory system, skin, gastrointestinal tract and cardiovascular system. The supervising physician must have appropriate medications and training in the treatment of anaphylaxis. Patients are not to receive their allergy injections anywhere except in the physician’s office. It is recommended that a minimum in-office observation period of thirty minutes be observed following injections.

__________________________________
Name of Supervising Physician (print)

__________________________________
Signature of Supervising Physician

__________________________________
Street Address

__________________________________
City	State	Zip

(____)______________(____)___________
Fax Number	Phone Number

Please have the physician who will be supervising allergy injections sign and return this form to the office where the patient records and antigen are kept.