INFORMED CONSENT FOR ALLERGEN X5170- 0415

IMMUNOTHERAPY WITH RAGWITEK®

o Carle Foundation Hospital_____________________________
o Carle Physician Group________________________________
o Carle SurgiCenter____________________________________
imprint o Hoopeston Regional Health Center_____________________
CONSENT

I authorize Dr._____________ as my physician, and other health care providers to administer RAGWITEK immunotherapy as discussed.
®

I understand that I will be taking one tablet of RAGWITEK® sublingual (under my tongue) every day until the end of the ragweed pollen
season.
I understand that the first dose of RAGWITEK® should be administered at a medical facility with a physician, or an Advanced Practice
Provider present since occasional reactions may require immediate treatment. For this reason, I understand that I am required to wait
in the medical facility after receiving my first dose for at least 30 minutes. I understand that if I tolerate this first dose, I can continue
taking RAGWITEK® at home for the duration of my treatment course.
I have been prescribed an auto-injectable epinephrine (epi-pen). I have received instructions and training on how to use it and when to
use it.
I understand that severe allergic reactions such as anaphylaxis can occur and may be life-threatening. I understand that any or all of
the following symptoms of an allergic reaction may occur and that I should use my epi-pen and then seek medical attention: trouble
breathing, swelling of the throat or tongue, throat tightness, trouble swallowing or speaking, dizziness or fainting, rapid or weak heart-
beat, severe flushing of the face, severe itching of the skin, severe stomach cramps or pain, vomiting or diarrhea. Although serious
reactions are rare, they can cause death. If a reaction does occur, I authorize my physician and other health care providers to provide
the necessary treatment to me.
I understand that the most commonly reported side effects were itching of the ears, mouth, lips, and tongue, swelling under the
tongue, or throat irritation. These side effects, by themselves were not dangerous or life-threatening.
I understand and agree to the following:
• If I have uncontrolled asthma symptoms or eosinophilic esophagitis (inflammation of the esophagus) or if I become pregnant I am
not to take RAGWITEK®.
• If I have any mouth sores or just had a dental procedure such as a tooth extraction with an open wound I am not to take
RAGWITEK®.
• When taking RAGWITEK® I am to remove the tablet from the blister package after carefully removing the foil with dry hands. I am
to place the tablet immediately under my tongue and allow it to remain there until completely dissolved. I am to wash my hands
after taking the tablet. I understand I am not to swallow for at least 1 minute.
• I should not have any food or drink for the next 5 minutes after taking my dose of RAGWITEK®.
• If I forget to take a dose of RAGWITEK® I should not take a double dose and should take the next dose at my scheduled time.
• If I miss more than one dose, I need to contact my Health Care Provider before restarting.
• If I start taking beta blockers or other new medications during my course of immunotherapy I will inform my Health Care Provider.
I have received the patient information sheet on RAGWITEK® immunotherapy and have had the opportunity to review it and have my
questions answered.
I acknowledge that the following have been discussed with me and that I have an understanding of my current medical condition, the
proposed treatment, including risks and benefits, probability of success, alternative treatments and their associated risks, as well as
the risks of not undergoing this treatment. I have had the opportunity to ask questions which have been answered to my satisfaction
and agree to proceed.

By signing this consent form I give permission to order and bill for RAGWITEK®. If for any reason I decide not to do the RAGWITEK®
treatment, I understand that I am responsible for any charges not covered by my insurance plan.

_______________________________________________________________ ________/________
Signature of Patient or Authorized Representative Date        Time

_______________________________________________________________ ________/________
Signature of Witness Date        Time

I have explained the proposed procedure, including risks, benefits and alternatives to the patient or authorized representative.
______________________________________ _______________________ ________/________
Signature of Practitioner Practitioner # (or badge #) Date        Time

Interpreter Services:
I have provided interpretation in _________________________ of any verbal and/or written information, including this
(type of language)
consent form, that have been provided to the patient/authorized person to consent.
Interpreter: __________________________________________ Date:________ Time:_______
(print full name/ badge #)
Signature (or if remote source, indicate company used): ________________________________________________________