Consent for Antigen Extract Preparation

  • Consent for Antigen Extract Preparation

    All antigen preparation for injections are custom mixed exclusively for each patient. Allergy Immunotherapy injections are both a time and financial commitment. You should sign this form ONLY if you are certain you want to proceed.

  • Date Format: MM slash DD slash YYYY
  • I have read the statement above. I accept financial responsibility for costs not covered by my insurance and hereby give AIRE Medical Los Angeles my consent to prepare my antigen extracts. I understand that my serum are prepared and billed for a one year (12-month) supply. Any unused serum or antigen remains my financial responsibility.