Consent for Penicillin Allergy Testing

I understand that penicillin allergy skin testing has certain advantages and disadvantages.

I also understand that any form of medical therapy may be ineffective or provide only partial relief including this form of allergy therapy. I understand also that it may have adverse side effects including, but not limited to: local reactions at the injection sites with redness, swelling, and discomfort; worsening of allergy symptoms with runny nose, nasal congestion, itching, difficulty breathing, worsening of asthma symptoms, and anaphylactic shock (a severe drop in blood pressure with swelling of various structures of the body including possible swelling of the airway).

I have informed the allergy staff and physician of all of the medications I am currently taking or have taken in the recent past. This includes any eye drops, blood pressure medication, steroids (Prednisone, Medrol Dose Pack), antidepressants, and allergy medications. If I neglect to inform them of the medications, I understand that there may be side effects when performing the allergy testing and I take full responsibility for this.

I give my consent for penicillin allergy testing and have full knowledge of the above information.

The insurance pre-certification we received at our office for your allergy tests is not a “guarantee of coverage or payment” by your insurance company. You are ultimately responsible for the charges if the insurance company fails to pay for the tests (in part or its entirety).

Date: __________________     Patient Name: ________________________________________

Signature of Patient or Legally Responsible Party

Date: ___________________   Witness: _____________________________________________