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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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/EPO Self-pay Please note your serums are prepared and billed for a one-year (12 months) supply, which starts from the time the serum is mixed. And upon receipt of a deposit payment as follows: ALL PPO/EPO 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 your 1) annual deductible or 2) co-insurance (patient responsibility after insurance has been paid), or both. Any unused or expired antigen remains your financial responsibility. If you are self-pay, please contact the front desk for pricing information.* I agree Product Name*New VialsRefillTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name I understand I must have an authorization of service by my insurance before receiving services Signature* Reset signature Signature locked. Reset to sign again
