Outside Facility Consent

• 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.

Release for Injections Administered at an Outside Medical Facility