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John C. Longest Student Health Center Mississippi State University CONSENT FORM FOR ALLERGY INJECTIONS Patient Name Patient Social Security Number Patient Date of Birth I authorize the physicians of the John C. Longest Student Health Center and such assistants that may be selected by them to perform the following procedure. My physician has explained the procedure necessary to treat my condition and I understand it to be as follows Allergy vaccine injections are given at the recommended intervals. I understand that there is the possibility of a local reaction at the site of injection or even a systemic reaction which could rarely result in death. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me about the results of this procedure. Longest Student Health Center and such assistants that may be selected by them to perform the following procedure. My physician has explained the procedure necessary to treat my condition and I understand it to be as follows Allergy vaccine injections are given at the recommended intervals. My physician has explained the procedure necessary to treat my condition and I understand it to be as follows Allergy vaccine injections are given at the recommended intervals. I understand that there is the possibility of a local reaction at the site of injection or even a systemic reaction which could rarely result in death. I understand that there is the possibility of a local reaction at the site of injection or even a systemic reaction which could rarely result in death. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me about the results of this procedure. Longest Student Health Center and such assistants that may be selected by them to perform the following procedure. My physician has explained the procedure necessary to treat my condition and I understand it to be as follows Allergy vaccine injections are given at the recommended intervals. I understand that there is the possibility of a local reaction at the site of injection or even a systemic reaction which could rarely result in death. My physician has explained the procedure necessary to treat my condition and I understand it to be as follows Allergy vaccine injections are given at the recommended intervals. I understand that there is the possibility of a local reaction at the site of injection or even a systemic reaction which could rarely result in death. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me about the results of this procedure.

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