Antigen consent template 2026

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The document is a Release of Antigen Consent Form for allergy extract administration, requiring patient or guardian consent for treatment under the supervision of Dr. Travis A. Miller at The Allergy Station in Roseville, CA. It outlines the responsibilities of the supervising physician and confirms that allergy injections will be administered in-office.

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Click ‘Get Form’ to open the antigen consent template in the editor.
Begin by entering the patient’s name in the designated field labeled 'PATIENT NAME'. Ensure accuracy for proper identification.
Next, fill in the 'DATE OF BIRTH' field with the patient's birth date. This information is crucial for medical records.
In the section requesting administration details, confirm that the allergy extract will be administered under the supervision of Travis A. Miller, MD.
Sign in the 'Signature of Patient' field and enter today's date to acknowledge consent.
The supervising physician must print their name and provide their signature along with the date to confirm their responsibilities.
Finally, ensure that all facility information is correctly filled out, including 'NAME OF ALLERGY FACILITY', 'FACILITY ADDRESS', and 'FACILITY PHONE NUMBER'.

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