Allergy Skin Testing Consent Form

Please read all information carefully before signing this consent for testing

Purpose

Allergy Skin Testing is a method of testing for allergic antibodies. Allergic antibodies are produced by your immune system after repeated exposure to allergic substances (e.g. pollen, cat dander). Not all people have allergic antibodies and not everyone with allergies will produce antibodies to all allergic sources. Allergy skin testing helps to confirm which substances (if any) may be causing your allergic symptoms.

The results of the skin tests will be correlated with your clinical history and description of allergy symptoms. Positive tests indicate the presence of allergic antibodies, but a positive skin test result does not necessarily indicate that the allergen will cause symptoms.

Method

The allergy skin test method used in this clinic is Skin Prick Method where the skin is pricked with a disposable plastic applicator that delivers a very small amount of allergenic extract into the skin surface. Each applicator tests ten (10) allergens and as many as eight (8) applicators will be applied to either your arms or back. No needles are used in this method.

Allergens

You will be tested for a variety of important and/or food allergens. These airborne allergens include pollen (from trees, grasses, & weeds), molds, dust, mites, and animal dander. The allergens in your testing panel represent the most common food and/or inhalant allergens (including those airborne allergens found in residential and work environments).

Expectations

An allergy skin test consists of introducing small amounts of the suspected allergic substance into the skin and noting the development of a positive reaction which consists of mild swelling and redness (similar to a mosquito bite). The procedure takes less than 5 minutes to administer and the results are read approximately 15 to 20 minutes after the application of the allergen.

Any positive reactions will gradually disappear over a period of 30 to 60 minutes, and, typically, no treatment is necessary for this itchiness. Most patients report the procedure to be pain free though you may feel a pricking sensation during the application of allergen, and many patients will experience some itching.

Medications to Avoid

4-5 days prior: No prescription or over the counter oral antihistamines should be used. These include cold tablets, sinus tablets, hay fever medications, or oral treatments for itchy skin, over the counter allergy medications such as Claritin, Zyrtec, Allegra, Actified, Dimetapp, Benadryl, and many others.

3 days prior: Over the counter sleeping medications (e.g. Tylenol PM) also contain active ingredients that interfere with histamine.

2 days prior: Discontinue nasal and eye antihistamine medications, such as Patanase, Pataday, Astepro, Optivar, or Astelin.

2 weeks prior: Other prescribed drugs, such as amitriptyline hydrochloride (Elavil), hydroxyzine (Atarax), doxepin (Sinequan), and imipramine (Tofranil) have antihistaminic activity. Do not stop taking these medications before consulting with your physician first.

Adverse Reactions

Although adverse reactions to skin testing are rare, your test will be administered at this medical facility with a medical physician or other health care professional present since occasional reactions may require immediate therapy. These reactions may consist of: itchy eyes, nose, or throat; nasal congestion; runny nose; tightness in the throat or chest; increased wheezing; lightheadedness; faintness; nausea and vomiting; hives; generalized itching; and shock (under extreme circumstances).

Please let the physician and nurse know if you are pregnant or taking beta-blockers. Please note that these reactions rarely occur but in the event a reaction would occur, the staff is fully trained and emergency equipment is available.

Important Information

Fasting is not necessary, but please avoid sunburns or excessive sun exposure immediately before allergy testing
Please bring in a list of your current medications
Inform us if you are or possibly are pregnant
Inform us if you are wheezing or have a fever
Please give us at least 48 hours notice if you need to change your appointment
We request that you do not bring small children unless accompanied by another adult

Consent for Administration of Allergy Skin Testing

I have read the information in this consent form and understand it. The opportunity has been provided for me to ask questions regarding the potential risks of allergy skin testing, and these questions have been answered to my satisfaction. I understand that precautions consistent with the best medical practices will be carried out to protect me from adverse reactions to skin testing. I do hereby give consent for the patient designated below to be tested with allergenic extracts by skin prick testing, as recommended by a physician.

I acknowledge that I have read and understood all the information above, and I consent to allergy skin testing

Patient Information

First Name *

Last Name *

Date of Birth *

Name of Immunotherapy Patient *

Medical Record Number *

Patient Signature (or Legal Guardian) *

Preferred Location *

Date Signed *