Office: 615.460.5506 Fax: 615.460.6131 1900 Belmont Boulevard Nashville, TN 37212 To whom it may concern: Belmont University Health Services offers allergy injections to Belmont students and staff We are staffed with a nurse practitioner at all times that allergy shots are given We have the following available to treat potential reactions to an allergy injection: Oxygen Epinephrine Benadryl Albuterol nebulization IV fluids All patients are required to wait 20 minutes after allergy shots, unless allergist requires 30 minutes Allergy serum may be sent with the patient or mailed to: BELMONT UNIVERSITY Health Services 1900 Belmont Boulevard Nashville, TN 37212 Please include dosage instructions and shot record, including adjustments for lateness or local reactions We will fax shot record with refill request when needed We will contact you with any questions regarding your patient’s immunotherapy treatment In order for the patient to receive allergy injections at our clinic, please sign and date the bottom of this form and return to us at the above address or fax number I give my permission for (Patient name and DOB) to receive allergy injections at Belmont University Health Services Provider Name: Provider Address: Provider Telephone: Provider Signature: If you need any additional information, please feel free to contact us Krystal Huesmann, RN, BSN (615-460-6194) Amy Lewis, APRN, FNP-BC (615-460-5616) Date: _