Formulario de Consentimiento Para Inmunoterapia Con Alérgenos

Recibirá un extracto que contiene una mezcla de alérgenos a los que es alérgico. Por esta razón, existe el riesgo de reacciones alérgicas.*
Es muy importante que nos informe de inmediato si ha estado enfermo o ha tenido algún cambio de medicación reciente.*
He hablado sobre las inyecciones para las alergias y los riesgos con mi proveddor.*
ntiendo que debo notificar al Departamento de Facturación inmediatamente de cualquier cambio de seguro u otras circunstancias que puedan afectar la facturación.*
Verifique el costo del paciente antes de hacer el extracto*
En Arizona Allergy Associates haremos todo lo posible para determinar sus beneficios de alergia, pero le recomendamos encarecidamente que llame a su compañía de seguros para verificar su cobertura personal de inmunoterapia con alérgenos. Los códigos para las vacunas contra la alergia y el extracto de alergia son los siguientes: 95115, 95117, 95165 y 95170. Algunos pacientes pueden ser candidatos para la Terapia en grupo y los tratamientos iniciales se facturan con el código 95180. Todos los saldos impagos del extracto de alergia deben pagarse en su totalidad antes de la renovación de su extracto.
Nombre de la Parte Responsable*
Nombre del Paciente*
Fecha de Nacimiento del Paciente*
Notificación*
Nombre*
Tipo de notificación*

Escriba el nombre para la firma.
Fecha*
Consintimiento*

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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.