Allergy Injection Release Form

For Staff and Students Requiring Allergy Injections

The Health Center can administer allergy immunotherapy prescribed by an outside doctor. Injections can be continued on a schedule that has been established by your allergist or treating physician. Our guidelines require several pieces of documentation in order for our staff physicians to supervise the injections. They are as follows:

  1. The name, address, phone and fax number of your treating physician.
  2. An antigen injection schedule - this should include an area to record the date, antigen, dilution, dosage and injection site.
  3. Antigen administration instructions - any routine or special instructions for our nursing staff should be included here.
  4. Instructions for missed doses, local or systemic reactions.
  5. A copy of the note from your last clinic visit with your physician.

We will require these five pieces documentation for all staff and students receiving continuing allergy immunotherapy at the Health Center. Your doctor may call us with any questions he or she may have. Initial injections should be given at your own physicians’ office. The health center will not initiate immunotherapy.

Allergy Injection Release Form (PDF)
(Right-click and select "Save as" to download the file to your local machine.)