Shotconsent2013

Strauss Allergy and Asthma
www.straussallergyasthma.com
ALLERGY IMMUNOTHERAPY

Allergy immunotherapy, commonly referred to as allergy shots, is a safe and effective way to treat
nasal symptoms and asthma which are triggered by inhaled allergens. Inhaled allergens are foreign
substances, such as pollen, dust particles and animal danders, which can provoke an allergic reaction.
These reactions are all too familiar as sneezing, nasal congestion, runny nose, eye irritation, cough,
and wheezing. Depending on the types and number of specific allergens one is allergic to these may
be limited to a specific season or occur on a year-round basis.
There are three types of treatment options available to the allergy sufferer. The first is complete
avoidance of the allergen. Unfortunately this may be difficult or impossible in many cases.
However, efforts to limit allergen exposure can provide a great deal of relief and should not be
overlooked. The second option is to use medications such as antihistamines and prescription nasal
sprays. The third option is allergy shots (immunotherapy). Patients who are very uncomfortable
because of their allergies may need to use a combination of the above treatments to obtain optimal
relief.
Allergy immunotherapy works by diminishing the allergic response. The patient receives gradually
increasing amounts of a purified vaccine of the specific allergen(s) they tested positive for such as
pollen, animal danders, dust mites or mold. Immunotherapy changes the way your immune system
responds to those allergens, decreasing symptoms as time and the dose increase. During the build up
phase, we generally recommend that you come in once a week for the first 6 months (or twice a week
for 3 months). Once a sufficient dose is achieved and symptoms have improved, we extend the
interval gradually. Most patients will wind up coming in monthly and stay on shots for about 5
years, although there is a good deal of variation depending on individual circumstances.
What are the side effects of allergy shots?
There are two types of adverse reactions which can occur in response to allergy immunotherapy:
1) Local reactions consist of redness, swelling and itching at the site of the injection, occurring from minutes to several hours later. These are common and can be treated by applying ice packs to the site of injection and taking an antihistamine (e.g. Claritin, Zyrtec or similar product). 2) Systemic reactions are rare and consist of generalized symptoms which can include shortness of breath, wheezing, fainting, shock and may be life-threatening. These reactions can usually be reversed promptly by appropriate medical treatment under a physician’s care. Because of these possible serious adverse reactions, WE ASK THAT YOU WAIT A MINIMUM
OF 30 MINUTES EACH TIME YOU RECEIVE AN INJECTION. Please note that such a
reaction may occur at any time, even after you have been on maintenance therapy for years. (OVER)
We will meet with you periodically for an office visit to assess your response to treatment and review
your medical care. Office visits will be done every 90 days for patients in their first year of therapy
and for all patients with asthma. Insurance companies will often not cover an office visit on the same
day as an allergy shot, so office visits must be scheduled on a separate day from the shot.
There are currently two allergy shot schedules:
The conventional shot schedule is given once or twice weekly. It takes 16-20 injections to get to
maintenance or high doses when improvement can be expected. The required waiting period after
the injection(s) is 30 minutes.
We now offer a rush schedule in which doses are advanced more rapidly. Two or three doses are
given consecutively every 15-20 minutes during a visit. The advantage is that high doses can be
obtained in 3-6 sessions and you can expect improvement much sooner than with the conventional
allergy shot schedules. The total time in the office for these visits is 60-90 minutes. We require that
you wait in the office for 30 minutes after the last injection is given in this schedule. There is an
increased risk of localized swelling of the arms with this schedule and increased risk of systemic or
anaphylactic reactions which is why the extended waiting time is required. If you are on a rush
schedule, take an antihistamine ex. Cetirizine (Zyrtec), Fexofenadine (Allegra), or Loratidine
(Claritin) at least one hour before your first injection. Patients on a rush schedule will have a
copayment for a regular office visit for each treatment session while on this schedule.
You can switch schedules. If you do not have the time to spend in the office and would prefer only
one shot that day, that is fine. Patients may switch from one schedule to another depending on how
they are doing. The doctor will go over these options with you.

What do allergy shots cost?
Allergy shots are covered by most insurance companies. There may be a co-payment for each visit.
Please contact your insurance company to find out your coverage. The codes you will need are:
95115 and 95165; or 95117 and 95165. If you are paying out of pocket, please ask for our fee
schedule. Allergy shots are usually cost-effective in the long run because they will decrease your
need for other medications, sick visits, and time lost from work or school.

We prepare your allergy shots in advance to minimize your wait time. IF you can not make your
appointment for your allergy shot, please call to cancel. If you do not provide us with 24 hours
notice, you may be charged a fee of $30 to cover the cost of the wasted vaccine. This fee is not
covered by insurance.
I have reviewed the benefits and risks of allergy immunotherapy, the office procedure and policy
statement and consent to its administration. I understand that I am financially responsible for all
services provided.
Name of Patient: ____________________________________
__________________________________________________

Source: http://www.straussallergyasthma.com/shotconsent2013.pdf