Allergy Desensitization Form History Instructions From Ordering Physician NP or PA This form must be completed in full and submitted with a copy of the most recent o31ce visit note prior to ID: 947200
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FORM - Allergy Desensitization Form - 05262022 Allergy Desensitization Form History & Instructions From Ordering Physician, NP or PA This form must be completed in full and submitted with a copy of the most recent o ce visit note, prior to starting injections at University Health Services. Vials must be clearly labeled and correspond with the written instructions and dosage sheets. Prescribing Provider must provide dosage adjustment instructions for missed/late injections and local reactions. UHS ALLERGY/IMMUNIZATION CLINIC INFORMATION: Contact Information: O ce 512-475-8301, Fax 512-471-7119 Mailing Address: UT Austin, University Health Services, ATTN: A/I Clinic, 100 West Dean Keeton STOP A3900, Austin, TX 78712 Location: Student Services Building (SSB) 2.102 PRESCRIBING PROVIDER INFORMATION: Licensed (circle one): Physican Physician Assistant Nurse Practitioner Texas License Number: ___________________ Name: Address: office fax numberoffice hours PATIENT INFORMATION: Name: Date of Birth: Patient has been receiving immunotherapy in my o ce since Date: Patient has had a systematic reaction in the past. If yes, date and description: No Yes Oral antihistamine required before injection. No Yes Patient required to carry their own epinephrine auto-injector on shot days in case of reaction after leaving the allergy clinic. No Yes Patient has asthma. No Yes Patient required to take maintenance asthma medication/inhaler to receive injections. If yes, list drug/instructions: No Yes Patient required to have Peak Flow measured.* If yes, before/after injection (circle). Minimum Peak Flow to receive injections: Patient’s personal best PF: *not performed in the clinic until further notice due to COVID-19 No Yes Patient permitted to have u vaccine at same visit as allergy injections. No Yes Medications patient is taking, dosage, frequency (attach medication list if necessary): Other pertinent diagnosis: I request that University Health Services administer allergy immunotherapy to this student according to the instructions and schedules submitted by me. physician, np, or pa printed name physician, np, or pa signature date UHS Sta Review: uhs nurse signaturedate N/A not licensed in Texas (UHS will assist students to establish with a local provider if their allergist is not authorized to practice in Texas) University Health Services