The Allergen Immunotherapy (Allergy Shots) Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, healthcare, allergy, immunotherapy, anaphylaxis, allergy shots. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Allergen Immunotherapy (Allergy Shots) Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Allergy Practice / Clinic:** ___________ **Supervising Allergist / Immunologist:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Referring Diagnoses:** ___________ *E.g., allergic rhinitis, allergic asthma, allergic conjunctivitis, insect venom hypersensitivity, atopic dermatitis* --- ## 1. Description of Allergen Immunotherapy **(a)** Subcutaneous allergen immunotherapy (SCIT), commonly called "allergy shots," is an evidence-based treatment that gradually desensitizes the immune system to specific allergens. It is the only disease-modifying therapy available for IgE-mediated allergic conditions; it does not merely suppress symptoms but can reduce the need for daily allergy medications and provide long-lasting benefit after the treatment course is complete. **(b)** Treatment consists of two phases: - **Build-up phase:** Weekly (or more frequent, for rush/cluster protocols) injections of escalating allergen doses over approximately **___________** until the maintenance dose is reached. - **Maintenance phase:** Injections at the maintenance dose every **___________** for a recommended total treatment duration of **___________**. **(c)** The allergen extract will be prepared based on allergy skin-test or specific IgE results and will target the following allergen classes: **Allergen Classes in the Extract:** ___________ *E.g., dust mite (Dermatophagoides pteronyssinus and D. farinae), cat dander, dog dander, grass pollens, tree pollens, weed pollens, mold (Alternaria, Cladosporium), cockroach, insect venoms (yellow jacket, honeybee, paper wasp, white-faced hornet, yellow hornet)* --- ## 2. Risks of Allergen Immunotherapy **(a) Local reactions** (common, expected): redness, swelling, or itching at the injection site. Usually mild and self-limiting. Treated with a cold pack and antihistamine.