Allergy Testing Medication Consent

Eric D. Reed, D.O.

301 W 19th Street

Mount Pleasant, TX 75455-2322

903-577-1101

Allergy Testing Medication Consent

Most medications do not interfere with skin testing, but there are a select number that will affect the test. Make certain that the nurse is aware of all medications that you are taking prior to testing. Please notify the physician and/or nurse if you are taking any antihistamines, anti-depressants, H2 blockers, beta blockers. Please also notify the physician/nurse/office staff if you: are pregnant, have fever, wheezing, trouble breathing, history of asthma, and if you have a history of a severe allergic reaction.

Antihistamines (PLEASE STOP 7-10 DAYS PRIOR TO TEST):

(Antihistamines can include certain eye drops, nasal sprays, sleep aids, cough suppressants & OTC allergy relief.)

Actifed, Allegra/Allegra D (Fexofenadine), Alavert, Astelin, Atarax, Atrohist, Benadryl, Bromfed, Claritin/Claritin D (Loratadine), Clarinex,Diphenhydramine, Dimetapp, Doxylamine, Dristan, Drixoral, Dura-Vent, Hydroxyzine HCl, LoHist DM, Meclizine, Patanase, Phenergan,Tavist, Tussionex, Tylenol (PM/Allergy/Cold), Unisom, Vistaril, Xyzal, Zyrtec/Zyrtec D (Cetirizine), Zutripro

H2 Blockers (PLEASE STOP 2 DAYS PRIOR TO TEST):

Famotidine (Pepcid AC, Pepcid Oral), Cimetidine (Tagamet, Tagamet HB), Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac Injection, and Zantac Syrup), Nizatidine Capsules (Axid AR, Axid Capsules)

Beta Blockers (PLEASE DO NOT STOP UNTIL WE CALL YOUR DOCTOR; 3-4 DAYS):

Betapace/Sorine (Sotalol), Blocadren (Timolol), Brevibloc (Esmolol), Bystolic (Nebivolol),Cartrol (Carteolol), Coreg (Carvedilol), Corgard/Corzide (Nadolol), Inderal(Propranolol), Inderal-LA (Propranolol), Kerlone (Betaxolol), Levatol (Penbutolol), Lopressor (Metoprolol), Normodyne/Normozide (Labetolol), Sectral (Acebutolol), Tenoretic/Tenormin (Atenolol), Toprol-XL (Metoprolol), Trandate (Labetalol), Visken (Pindolol), Zebeta (Bisoprolol), Ziac (Bisoprolol&HCTZ)

Please note: You need to wait ONE WEEK to test if you have had the Flu or Pneumonia Shots.

*The preceding list is not all inclusive; if you are concerned about a medication that is not listed, please call our office.*

Ihave read over this list of medications and am aware that Mt. Pleasant Ear, Nose, and Throat Clinic WILL NOT perform the allergy testif I am still on any of the preceding medications or medication types.(This is for your protection. If we test while you are on any of these medications the results will be altered.)

I am taking a Beta Blocker and am aware that I SHOULD NOT suspend use of this medication without consent of my managing doctor (which Mt. Pleasant Ear, Nose, and Throat will obtain).

For Beta Blockers, please list managing doctor: ______

______

Signature of Patient or Responsible Party Date