Informed Consent Order Form - Allergy

Patient Name: _____________________________________________________
Patient DOB: _____________________________________________________
Provider Name: _____________________________________________________

Please Obtain Informed Consent for the Following:

   Possible Only
Allergen Immunotherapy (12449)
Allergy injections begin with very small amounts. The amount given to you will increase with each weekly shot until a therapeutic dose...
Allergy - Intradermal Skin Test (12870)
This test involves injecting a possible allergen under your skin. This will show if you have an allergy. Material causing an allergy is known as...
Allergy - Patch Test (18189)
This procedure involves placing suspected allergens on the surface of the skin. A substance causing an allergy is known as an allergen....
Allergy - Prick or Scratch Skin Test (12872)
This test involves placing a small amount of a liquid containing an allergen on your skin. This will show if you have an allergy to this...
Benralizumab Injection (23114)
This procedure involves an injection of a medicine. This medicine is not used to treat an acute asthma attack. It is used with other medicines to...
Bronchoprovocation Challenge Testing (12871)
This procedure involves taking a breathing test before and after inhaling an aerosolized medicine. The medicine may be methacholine, histamine,...
Dupilumab Injection (22888)
This procedure involves a series of injections (shots) of dupilumab. This medicine will be given using an injection under the skin of your...
Exercise Challenge Test (Asthma) (12869)
This test involves determining if your asthma symptoms are made worse or caused by exercise. Your lung function will be measured using a test...
Intraprocedural Administration of Iodinated Contrast for High Risk Patient, Allergy (23061)
This treatment involves injecting intravenous contrast dye during imaging or medical procedures. Your doctor has determined that you have an...
Medication Challenge Test (20688)
The goal of the challenge test is to see if you can safely take a medicine which you or your doctor suspects you may not tolerate. This procedure...
Medication Desensitization (20716)
This procedure involves giving you a medicine in small, gradual doses, building up to the full dose. This is usually a medicine you have taken in...
Omalizumab Injection (17710)
This procedure involves a series of injections of omalizumab (brand name Xolair®). This shot will be given often in your upper arm, and is given...
Oral Food Challenge Test (17724)
This procedure involves eating small amounts of the food that you may be allergic to. This test is done in a doctor’s office or an intensive...
Rush Immunotherapy (20717)
This treatment involves building up your tolerance to an allergen very quickly, usually within hours or several days. This will be done by giving...
Sublingual Immunotherapy (22962)
This treatment involves placing allergy drops or tablets under your tongue, where they are absorbed. Allergy drops or tablets contain amounts of...

Additional Notes (include Anatomical Side/Location if Applicable):

Order Form Accurate Until 11/2/2021