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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Please note your serums are prepared and billed for one-year (12 months) supply, and upon receipt of a deposit payment as follows: ALL PPO patients are required to pay an upfront deposit of $500 (new vials) and $200 (for refills) This is a deposit we collect to be applied towards either your1)Annual Deductible, or 2) Co-insurance (patient responsibility after insurance has paid), or both. *In the event you have no deductible or have met your out-of-pocket maximum for the year, the deposit amount will be applied towards the cost of your shots over the next 12 months. Any unused or expired antigen remains your financial responsibility.* I agree Product Name*New VialsRefillTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name I understand I must have an authorization of service by my insurance before receiving services Signature*
