Immunotherapy Consent

1. I understand sublingual immunotherapy is an allergy drop that is taken under the tongue in an attempt to improve allergy symptoms over time by strengthening my immune system, which, in most cases, leads to individuals becoming desensitized to allergy triggers.

2. I understand that this immunotherapy does not replace the avoidance of allergens to which I am known to be sensitized (allergic) and that the overall effectiveness of the sublingual immunotherapy also depends on external factors such as environment, diet, and use of other medications.

3. I understand that reduction of allergic sensitivity is the goal of sublingual immunotherapy. Improvement is often not seen immediately, and may not be apparent for up to one year. The results are often a reduction, but not complete elimination of symptoms. A few patients may not be helped by immunotherapy at all. I recognize that there is no guarantee that this therapy will, in fact, result in a cure or resolution of my symptoms and that these claims and this therapy has not been reviewed by the Food and Drug Administration.

4. I understand that anaphylaxis, an acute and potentially life-threatening allergic reaction, is a possibility during treatment. Though the risk of anaphylactic shock is low, I acknowledge that I am encouraged to have an EpiPen nearby when taking my first dose, I understand that Nectar can provide a prescription for an EpiPen after my virtual consultation if I so request.

5. I agree to use only the Nectar pharmacy to purchase and receive my prescriptions.

6. I understand and agree that, at this time, I do not wish to be contacted by telephone for medication counseling by a pharmacist.

I have read and fully understand this consent form, and consent to be treated with sublingual immunotherapy. I understand that I should not agree to this consent form if all items, including all of my questions, have not been explained or answered to my satisfaction or if I do not understand any of the items or words contained in this consent form.