We understand the desire to have allergy extracts administered out of our office and are happy to work with you to transition your serum. The shots MUST be given at a medical facility & the person administering the injection must be a physician, physician assistant, nurse, or medical personal that is equipped in handling severe allergic reactions such as administering epinephrine and/or performing CPR. Once allergy extracts are taken out of our office, we believe the person/facility administering the injection(s) assumes all responsibility for any side effects associated with immunotheraру. As a patient on immunotherapy, I understand that it's required for me to have an annual follow-up visit with my doctor. I agree to pay the shipping and handling fee of $30.00 prior to having BVAA ship my allergy serum to another facility via UPS. If you have a credit card on file, we will charge that. If not, you may pay over the phone

I acknowledge that I have read and understood the above information regarding out-of-office administration of my allergy immunotherapy, including the requirement that injections be administered at a medical facility by qualified personnel, my assumption of responsibility once the serum leaves this office, the need for an annual follow-up visit with my doctor, and the $30.00 shipping and handling fee. I agree to these terms.(required)

Patient First Name*

Patient Last Name*

Name of the facility/doctor*

Phone/Fax number*

Address*

Signature of patient/patient guardian*

Date Picker*

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