Allergy Extract Quote Received

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I WANT to proceed with Allergen Immunotherapy

I have received my allergy extract quote, and I wish to proceed with Allergy Injections. I understand that Arizona Allergy Associates will make my allergy extract and billed to the responsible party (my insurance company or me).

I further understand that Arizona Allergy Associates will bill me for any costs not covered by my insurance.

The previous consent I signed will remain in effect.

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I DO NOT want to proceed with Allergen Immunotherapy

I have received my allergy extract quote and I DO NOT wish to proceed with allergy injections at this time. If my circumstances change, I will need to sign a new consent.

I am rescinding my signature on the former Allergy Extract Consent. Arizona Allergy Associates may not make allergy extract, nor should they bill my insurance.

I understand that I may not rescind my signature for services already rendered.

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