Microsoft word - allegy injection(s) consent policy form.docx

Butler University Health Services
Allergy Injection(s) Consent / Policy Form
Allergy Injection(s)
Butler University Health Services will administer allergy shots to students who have the Required Information for the Administration of Allergen Immunotherapy Form, from their doctor, a signed consent form and serum. Students are seen for allergy injections only by appointment. Please see our policy regarding allergy shots below. If you do not wish to utilize our services for your allergy shots, there are private allergists in the Indianapolis area who will administer allergy serum. 1. The student/patient is responsible for providing the allergy serum. 2. Allergy serum must be accompanied by explicit directions for administration, late instructions, date of last injections, and a list of allergens in each bottle. 3. Each vial is to be labeled with the patient's name and an expiration date. 4. The above criteria must be met prior to administration of allergy serum by our health 5. If you are so late for your shot that your allergist's written instructions do not apply to the situation, it is your responsibility to call your allergist's office and ask them to fax us
6. Visit for appointment times. 7. Injections are administered by a nurse. Disposable syringes and needles are provided. 8. You must report to the nurse any current illness or any prescription or non-prescription medications you are currently taking prior to receipt of an injection. 9. All reactions must be reported to the nurse before you receive your next injection. Local reactions consist of swelling and itching at the injection site. Please measure the size of the swelling (not the area of redness) and record the length of time the swelling lasts. 10. After the injection, the student must wait at least 20 minutes. If your allergist's instructions call for a longer wait then you must follow those instructions. The injection
site must be checked by a nurse before the student leaves health services. Inform the
nurse immediately if you are having any itching, hives, coughing, sneezing, tightness in
the chest or throat, wheezing, or difficulty breathing. If you have any of these symptoms
after your departure call 911(cell) or (317) 940-9999 (campus phone)
11. WARNING: Individuals who are using a class of medication called a beta blocker
probably should not be on allergy injections. Examples of these drugs include Inderal,
Lopressor, Tenormin and Corgard
, as well as others. Please let us know if you are
taking any of these medications.
12. Students are responsible for taking their solution and instructions with them if they will need an injection while away from Butler University. 13. Health Services provides storage for allergy serum. Reasonable care is taken to insure their safety. Refrigeration temperatures are monitored daily and if the temperature is out of range, it is addressed promptly and vaccines are moved to a different storage location, however, power outages or other malfunctions my cause temperatures to reach levels which may cause damage to the vaccine. 14. Please be advised that Health Services will not assume financial responsibility for damage caused by such unforeseeable occurrences. In the event of probable damage to your serum, you will be notified to obtain fresh serum from your providing physician. 15. If you discontinue the treatment or fail to appear for treatment for a period of ninety days, 16. Butler University Health Services prohibits storage of expired medications. Therefore, unclaimed allergy extracts will be destroyed on the last day of the month during which they expire. INFORMED CONSENT FOR ADMINISTRATION OF ALLERGEN IMMUNOTHERAPY
I have read or have had explained to me the information in the Allergy Injection Policy. I have
had the opportunity to discuss these instructions and agree to follow them.
Parent’s/Legal Guardian’s Signature (if under 18 yrs.) Butler University Health Services
The Administration of Allergen Immunotherapy Please Print Or Type The Following Information Patient Name:__________________________________ Date of Birth:___________________________________ Diagnosis: _____________________________________ **ICD-9 Code(s) __________________________ History (including previous reactions): Date and Amount of Last Injection(s):__________________________________________________________________________ Content, Dilution:__________________________________________________________________________________________ Expiration Date of Vial(s)_____________________________________________________________________________ Interval Between Injections: _________________________________________________________________________________ Recommended Dosage:____________________________________________________________________________________ Dosage Reduction for New Vials:_____________________________________________________________________________ Dosage Reduction for Lateness:______________________________________________________________________________ Physician's Signature __________________________________________ Date: _______________________________ Board Certified Allergist: _____ Yes _____ No Printed Name: ________________________________ Phone:
* Provision of this code will assist your patient in receiving the medical insurance benefits to which he/she is entitled.
Phone: (317) 940-9385
Fax: (317) 940-6403
Address: Butler University Health Services, 530 W. 49th St., Indianapolis, IN 46208

Physician Information Sheet
Allergy and Other Injection Orders
Allergy Immunotherapy: Patients requesting to have their allergy immunotherapy administered by the Butler University Health Services personnel should understand that we only offer this service in accordance with their doctor’s written and signed orders. The Required Information for the Administration of Allergen Immunotherapy form provides us with this order. Your patients will not be seen or evaluated for this problem by Butler University Health Services physicians, although students may schedule appointments for the purpose of receiving symptomatic treatment if they wish. Our nurses have standing orders for emergency situations in the event of adverse reactions. Should such a problem arise, our physicians are available for appropriate emergency treatment as necessary. In order to provide these services, please complete the Administration of Allergy Immunotherapy form and either: • Fax: (317) 940-6403 • Mail: Butler University Health Services 530 W. 49th Street Indianapolis, IN 46208 • Student: bring the form to Butler University Health Services located on the south end of the Health and Recreation Complex. Our nurses will not administer allergy injections until this form is received. Please call (317) 940-9385 with any questions about this form. Allergen vials can be sent with the patient or can be mailed directly to our facility. These are stored in our refrigerator and the student may request the vials be released to them as needed for injections during times away from the university. If a student fails to appear for injections for more than 90 days, the vials will be discarded. If the student fail appointments or does not follow Butler University Health Services Allergy Injection Policy they may be referred to an allergist in town to continue immunizations. Other Medication Injections: Butler University will require an assessment by the student’s physician/specialist for the administration of other injectable medications. Documentation of the underlying diagnosis and previous treatment will be needed and the student should have that information available at the time of their appointment. For certain high-risk injectable medications, Butler University Health Services may need to refer the patient to an appropriate local consultant for further evaluation and/or administration of that medication. This is to promote appropriate quality control and safety for our patients. Students receiving ongoing medication injections are advised to schedule an appointment with Health Services by calling (317) 940-9385.


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