Outside Facility Consent | AZ Allergy

"*" indicates required fields

Release for Injections Administered at an Outside Medical Facility

I have read the immunotherapy Information Sheet.
I will not attempt to administer the extract to myself.
I will not permit anyone who is not a licensed physician, or under the supervision of a licensed physician, to administer these extracts.
I understand that I must wait 30 minutes in the medical facility in which I receive the injections, and have the injection site checked before leaving.

Facility where Injections will be Administered

Name of Facility:*

Phone*

Fax

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient's Name*

First Last

Date of Birth*

Today's Date*

Signature of Patient/Parent:*

Type name for signature.

If you would prefer to have your extract mailed, please be aware that there is a fee (prices may vary).

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