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.
Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Name of Parent/Guardian (if minor)
First Last
Patient Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
I have read the statement above. I accept financial responsibility for costs not covered by my insurance and hereby give Raffi Tachdjian MD 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.
What insurance do you have?*
- Medicare
- HMO
- PPO
If I wish to have any testing services performed in-office, and my insurance applies a deductible towards this service, I am aware that Raffi Tachdjan, MD collects an upfront $200.00 non-refundable deposit payable at the time of service. This amount is only a partial deposit towards my final balance, and in addition to any office visit copay and any patient balance after services are rendered.*
- I agree
Allergy Serum Test
Price:
Credit Card*

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Supported Credit Cards: American Express, Discover, MasterCard, Visa
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Signature*

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