Allergen Immunotherapy Consent Form

You will be receiving an extract containing a mixture of allergens to which you are allergic.*
It is very important that you let us know immediately if you have been sick or had any recent medication changes.*
I have discussed allergy injections and the risks with my provider at Arizona Allergy Associates.*
I understand that I must notify the Billing Department immediately of any insurance changes or other circumstances which would affect billing.*
Please check cost for patient prior to making extract.*
We at Arizona Allergy Associates will do everything possible to determine your allergy benefits, but we strongly encourage you to call your insurance company to verify your personal allergen immunotherapy coverage. The codes for allergy shots and allergy extract are as follows: 95115, 95117, 95165, and 95170. Some patients may be candidates for Cluster Therapy and the initial treatments are billed using code 95180. All unpaid balances on allergy extract must be paid in full prior to the renewal of your extract.
Name of Responsible Party*
Patient's Name*
Patient Date of Birth*
Notification Type*

Type name for signature.
This field is for validation purposes and should be left unchanged.


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Dear Arizona Allergy Associates Community,

We want to reassure you that we are taking all precautions to prevent the transmission of viral illnesses, including COVID-19. As always, our exam rooms and instruments will be sanitized between each visit and our waiting rooms will be sanitized regularly throughout the day. We are asking that all persons entering the offices wear face coverings. Additionally, please limit the number of persons presenting to the office; we ask that only one parent attends with a child and that additional siblings remain home.

As an extra precaution, we will not be seeing any sick visits or patients with fever or flu-like symptoms at present. We request that any allergy injection patients and/or patients with upcoming office visits reschedule if they have been in contact with someone with fever or flu-like symptoms.

If you suspect you may have a viral illness such as influenza or COVID-19 you should seek emergency care services or primary care services as we are unable to swab and test for these illnesses.

Finally, for all allergy injections patients: out of an abundance of caution and in order to limit your exposure to any viral vectors, we request that you limit close contact in waiting areas. At this time we will temporarily allow you to sit in your vehicle during your 30-minute wait. You will still be required to come in and have your arm read at 30 minutes or earlier if you are experiencing any reaction during your wait. We may also alter your shot schedule to limit your visits to the clinic temporarily.

Thank you for your understanding during these difficult times. These changes are temporary and we will keep you posted with any changes or additional information.