Healthcare Allergen Declaration

HEALTHCARE ALLERGEN DECLARATION

Patient Information

Emergency Contact

Insurance Information

Declared Allergens

Please indicate each known allergen category and provide specific substances, typical reaction(s), date of most recent reaction, and severity. If you have no known allergies, check the first box below.

No known allergies

Food Allergies

Medication Allergies

Latex / Rubber Latex

Environmental (pollen, dust, mold, animals)

Insect Sting / Venom

Contrast Dye / Imaging Agents

Other Allergens

Medical History & Current Management

I carry prescribed emergency medication(s) (e.g., epinephrine auto-injector)    If yes, specify medication and typical location:

Authorizations, Acknowledgments & Notices

I certify that the information provided in this Healthcare Allergen Declaration is complete and accurate to the best of my knowledge. I understand that withholding or misstating allergy information may result in inappropriate treatment and increase the risk of adverse reaction during evaluation or treatment.

I authorize the inclusion of the above allergen information in my medical record and allergen alert systems used by treating clinicians. I consent to reasonable notification of my emergency contact and primary care provider if a serious allergic reaction occurs or if a care team member determines that notification is clinically necessary.

I acknowledge that staff have explained the importance of carrying and correctly using any prescribed emergency medications. I understand my right to update or revoke this declaration at any time by submitting written notice to my treating provider; updates will be recorded in my health record upon receipt.

Privacy Notice: I understand that information on this form is protected health information. It will be used for my treatment, care coordination, and where required by law. Staff have provided an opportunity to ask questions about how my information will be handled.

This declaration is valid until revoked in writing (no expiration)

Patient Certification

By signing below I acknowledge that I have read and understand this Healthcare Allergen Declaration. I attest that the statements on this form are true and that I will notify my healthcare provider promptly of any changes to my allergy status or any allergic reactions I experience.

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