Dear ________

CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment ALLERGY TESTING PACKET
Name: __________________________________ Testing Date: _____________________ Test Review Date: _________________ Included: 1) Please obtain the appropriate allergy testing referral from your primary care physician. a. AETNA - 99499 minimum 3 visits. b. Keystone - “Evaluate and Treat” c. CIGNA - Prescription from your primary care physician for “Allergy Testing and Treatment” Any questions regarding referrals, please contact the office. 2) List of medications which are not compatible with allergy skin testing. DO NOT STOP TAKING THESE MEDICATIONS but do let the doctor know if you are on these medications. 3) List of allergy medications to stop taking before allergy testing. Non-compliance with testing
protocol will require test cancellation. The medications listed produce inaccurate results.
4) Allergy History Forms. Please complete the history forms before you come in for your allergy
testing.
PLEASE bring completed allergy testing packet to your allergy testing
appointment.
Please wear a loose/short sleeved shirt so we can access your arm for testing and
please bring your asthma inhalers if you use them
*** These tests are scheduled for 1.5 hours and are scheduled weeks in advance. We can typically only do
4-5 per day. When we get last minute cancellations, we can’t just “fit people in” since most patients need to
be off certain medications for a week before testing. If there is a chance you may not be able to make your
testing appointment, PLEASE let us know ASAP so we can try to fill the spot. If we can’t fill the spot, there
may be a cancellation fee! ***
460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977 CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment Allergy Financial Consent/Disclosure Form

NAME: _____________________________________ DOB: _________________ Date: ___________
All Allergy patients are required to check the terms of their Insurance Contract
regarding allergy treatment. You will find the phone number on the back of you
Insurance Card.
Some Insurance Companies (eg: Aetna) do assign co-pays for allergy testing and
injections. Please be aware that we are required to collect patient co-pays and
deductibles at the time of service.
Codes to verify Coverage are as follows:
Testing codes: 95004 & 95024
Treatment Codes: 95165 & 95117
CANCELLATION POLICY: Due to the extended appointment time reserved for
allergy testing, we must be notified within 3 business days or a $50 cancellation fee
may be charged.
Signed: ________________________________________________________________ (Patient)
Relationship to patient (for minors): _________________________________________
Witness: ___________________________________________
460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977 CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment
Patients who are taking BETA-BLOCKERS (including eye drops) or TRICYCLIC
ANTIDEPRESSANTS cannot get allergy skin testing.
They CAN get allergy blood testing (RAST). DO NOT STOP THESE MEDICATIONS UNLESS
DIRECTED BY THE PRESCRIBING PHYSICIAN (Family doctor, cardiologist, psychiatrist etc). Below is
a partial list of such medications:
BETA BLOCKERS:
Acebutolol
TRICYCLIC ANTIDEPRESSANTS: Amitriptyline Hydrochloride 460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977 CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment
MEDICATIONS TO STOP BEFORE TESTING
The following medications must be stopped prior to allergy testing and can be stopped WITHOUT asking
your doctor (it IS safe to stop these medications “cold-turkey).
Stop the following Antihistamines 1 week prior to testing:
Alavert
Allegra (Fexofenadine)
Allegra-D (Fexofenadine & Pseudoephedrine)
Atarax (Hyroxyzine HCL)
Benadryl
Cetrizine
Claritin (Loratidine)
Claritin-D
Clarinex
Clarinex-D
Diphenhydramine
Fexofenadine
Loratadine
Xyzal
Zyrtec
Tylenol PM
Exedrin PM
Any cough suppressants containing antihistamines
Stop the following (antihistamine sprays or drops) 3 days prior to testing:
Astelin (Azelastine)nasal spray
Astepro (Azelastine) nasal spray
Dymista (Azelastine Hydrochloride and Fluticasone Propionate) nasal spray
Patanase (Olopatadine Hydrochloride) nasal spray
Patanol (Olopatadine) eye drops
Optivar (Azelastine) eye drops
PLEASE MAKE US AWARE OF ANY otc MEDICATIONS YOU TAKE!

460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977 CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment
Allergy Testing & Treatment Consent Form

NAME: _____________________________________ DOB: _________________ Date: ___________
I authorize the physicians and associated assistants of CCOAA to perform skin prick and intradermal skin
testing upon myself / my child for the detection of possible allergies.
I further consent to the performance of such other or additional procedures different from that now
contemplated, whether or not arising from presently foreseen conditions, which the above named
doctors or their assistants may consider necessary or advisable in the course of the procedure. I have
been made aware of certain risks and complications that are associated with the allergy testing
procedure and allergy treatment. These include, but are not limited to hypotensive episodes (drop in
blood pressure), worsening of allergic symptoms (runny nose, itchy eyes, hives) and in rare cases,
anaphylactic reaction (severe allergic reaction) including possible death. I am aware that the practice
of medicine is not an exact science and I acknowledge that no guarantees have been made to me
concerning the results of this procedure or treatment.
This document has been fully explained to me and I certify that I understand its contents and agree with the above. Signed: ________________________________________________________________ (Patient)
Relationship to patient (for minors): _________________________________________
Witness: ___________________________________________
Informed Consent of Office Protocol
If I decide to initiate immunotherapy, I have been informed that I must wait up to 20 minutes in the office after each injection. This is for my protection. If an anaphylactic reaction should occur from an injection, it will usually happen within 20 minutes and can occur even though a person has been on the same treatment for years. I understand this and will not come in for an injection on a day when I cannot wait in the office for 20 minutes. I have also been informed of my obligations with respect to referrals, co-payments and other insurance related issues for which I am responsible. 460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977 CHESTER COUNTY OTOLARYNGOLOGY AND ALLERGY ASSOCIATES
A DIVISION OF PINNACLE EAR, NOSE AND THROAT ASSOCIATES
Adult and Pediatric Ear, Nose and Throat and Allergy Evaluation and Treatment Signed: _________________________________________ _______________________________
460 Creamery Way, #103 689 Unionville Rd. 795 E. Marshall St.,# 303 213 Reeceville Rd, #10 1 Commerce Blvd. #201 Exton, PA 19341 Kennett Square, PA 19348 West Chester, PA 19380 Coatesville, PA 19380 West Grove, PA 19390 610-384-8300 610-345-0977 610-384-8300 610-384-8300 610-345-0977

Source: http://ccoaa.com/wp-content/uploads/Allergy-Testing-Packet-All-Forms.pdf