"*" indicates required fields You will be receiving an extract containing a mixture of allergens to which you are allergic.* For this reason, there is a risk of allergic reactions. The most common reactions include local swelling and itching at the site of the injection. Some patients will experience nasal symptoms including runny nose and itching. Patients, especially those with asthma, may also experience wheezing. Severe allergic reactions such as anaphylaxis have rarely occurred and would involve wheezing, hives, swelling, gastrointestinal symptoms, low blood pressure, and, in very rare cases, death. The majority of reactions to allergy shots occur immediately after your injection; therefore, you will be required to wait 30 minutes after each shot.It is very important that you let us know immediately if you have been sick or had any recent medication changes.* You must inform our staff if you have been placed on BETA BLOCKER medications, as well. Please ask our nursing staff if you are unsure what medications are considered beta blockers.I have discussed allergy injections and the risks with my provider at Arizona Allergy Associates.* I give my permission for the allergy injection extract to be prepared and billed to the responsible payer (my insurance company or me). I have been given the opportunity to ask any and all questions I may have about the injections and am satisfied that they have been fully answered.It can take 4-6 weeks or 24-32 business days before your allergy extract is made and billed to your insurance.* If there are any changes to your insurance during that time, it will be your responsibility to advise our office as soon as possible. Any allergy extract that is made will be the sole financial responsibility of the patient in the event the insurance denies or applies a patient responsibility.I understand that I must notify the Billing Department immediately of any insurance changes or other circumstances which would affect billing.* I also acknowledge that I may be responsible for the costs of extract preparation if my insurance company recoups monies because I am non-compliant with the recommended course of medical treatment with immunotherapy.If there is a change to your insurance or you would like your current immunotherapy benefits, please complete the information below.Please check cost for patient prior to making extract.* Yes, please! No. 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, 95145, 95147, 95148, and 95149. 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* First Last Patient's Name* First Last Patient Date of Birth* Month Day Year Location Desired For Injections*ChandlerMesaPhoenixSan Tan ValleyScottsdaleNotification* I consent to receive notifications via Rosch regarding office closures, and Allergy Immunotherapy.Name* First Last Relationship to Patient* Cell #*Cell Phone Carrier* Would you like an extract cost quote?* Yes No. Do you have new insurance?* Yes No. Notification Type* Office Alerts Injection Past Due Signature* Type name for signature.Today's Date* Month Day Year Consent* By clicking submit I agree that I have read and will abide by all of Arizona Allergy Associates policies and that all information provided is accurate. Additionally, I acknowledge that this will serve as my electronic signature.CommentsThis field is for validation purposes and should be left unchanged. Δ
