Allergy Immunotherapy Services at Wellesley College Health Service Student Name: Date of Birth: Your patient has elected to receive allergy immunotherapy at Wellesley College Health Service. We are pleased to provide this service to her, acting in the capacity as an agent for you. If your patient is beginning immunotherapy, we require that the first two doses be given at your office. If this is not feasible, we would be happy to provide the names of local allergists to you for consultation and initiation of treatment. We do not provide immunotherapy for bees, wasps, or insects. In order to provide this service with the highest degree of safety, complete detailed instructions are required before we can begin allergy injections at our facility. Summary of our Allergy Injection Clinic Requirements, Policy and Services:

We require all new patients to have an Allergy Immunotherapy Intake appointment with one of our physicians
here at the Health Service. At this time their history will be reviewed by the physician and the Allergy
Immunotherapy Check Sheet
you are required to provide will be reviewed by the Registered Nurses. The
patient can receive their injections at the end of this appointment. Please recommend that your patient contact
us to arrange this required initial appointment well in advance to best accommodate their schedule.
Allergy immunotherapy is provided by two Registered Nurses, trained in BLS, during designated times when a
medical doctor is on site:
Our resuscitative equipment includes: Epinephrine injectable, Diphehydramine injectable, Albuterol Inhalation
Nebulizer, AED and supplemental O2. We are served by the town of Wellesley EMS system.
We are approximately 5-10 minutes away from the nearest Emergency Department.
We advise that student’s take responsibility for their serums and bring them to the Health Service for
refrigerated storage during their therapy with us. If shipping serums is necessary we recommend FedEx
delivery directly to the Health Services building during regular business hours to avoid serum remaining
unrefrigerated in the college’s general mail distribution center for an indeterminate amount of time. During
times when the Health Service is closed, and your patient decides to continue her injections with your office,
we will provide your patient with her serums and your Allergy Management Schedule. We will keep a copy of
the schedule in our medical record for reference.
When questions arise we will call your office and accept a Telephone Order from you or your nurse for a
change in orders or clarification. We will then fax a copy of the Telephone Order to your office for verification
and signature. We require that you fax this form back to us promptly for continuity of care.
Vanessa Britto, M.D., M.Sc.
Medical Director
106 Central Street, Wellesley, MA 02481 Tel 781.283.2810 Fax 781.283.3693

Source: http://www.wellesley.edu/sites/default/files/assets/letter_to_allergist.pdf


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