Informed Consent for Skin Testing

TO THE PATIENT: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks involved.

as my physician, and such associates, technical assistants, and other healthcare providers as necessary, to evaluate and diagnose my condition which has been explained to me as: suspected pollen, mold, environmental, or food allergy.

2. I understand that the following surgical, medical, and or diagnostic procedures are planned for me. I voluntarily consent and authorize these procedures: skin prick testing (small device that “pricks” the surface of the skin) and/or intradermal testing (tiny needle just like a TB skin test).

3. I understand that my physician may discover other or different conditions which require additional or different procedures than those planned. I authorize my physician, and such associates, technical assistants, and other healthcare providers to perform such other procedures which are advisable in heir professional judgement.

4. I understand that no warranty or guarantee has been made to me as to result, outcome, or cure.

5. I understand there may be alternatives to the planned procedure. Alternatives include but are not limited to: Do not perform skin testing. Blood testing can be performed for allergies as an alternative to skin testing. I have discussed this and other alternatives with the allergist and would like to proceed with skin testing.

6. I understand that oral antihistamines (ie. Claritin, Allegra, Zyrtec, Benadryl, etc) need to be stopped 1 week prior to skin testing, and I attest hat I have done so.

7. I realize and understand that surgical, medical, and/or diagnostic procedures have the potential risk for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also realize and understand that the following risks and hazards that may occur in connection with this particular procedure include but are not limited to:

• Local discomfort and itching (common)
• Minimal bleeding at skin test site (rare)
• Allergic reactions (rare) (
• MOST ALLERGIC REACTIONS if they occur will happen in the FIRST 20-30 minutes while you are here in the office. If you notice your body feeling different in any way, please inform the healthcare provider who is performing the tests. If a SEVERE reaction occurs, you may need a shot (injection) of adrenaline (epinephrine). Other medical interventions may also be required to treat severe reactions. Severe reactions that are not treated may become more severe and in rare cases (1 in 2.5 million chance) may result in death. If you experience any of the above listed signs or symptoms after you have left the office, you should contact the office immediately (Princeton office (609) 430-9200; Robbinsville office (609) 436-5740; Sewell office (856) 589-6673; Voorhees office (856) 772-1617), seek emergency medical attention (ie-nearest Emergency Room), or call 911. If the office is closed the operator will reach one of the physicians, but with the onset of any of the above symptoms you should not wait, and should instead go to the nearest Emergency Room for immediate evaluation and treatment, or call 911.

8. I have been given an opportunity to ask questions about my condition, alternative treatments, risks of non-treatment, the procedures to be used, the risks and hazards involved, and I have sufficient information to give this informed consent.

9. I would like to proceed with the above described testing