Consent for holding prescribed Beta-Blocker while undergoing Allergy Testing

I have reviewed the list below and have been informed of the potential life-threatening complications that may arise while taking a beta-blocker during allergy testing and I have obtained consent from my primary care physician to hold my prescribed beta-blocker while undergoing allergy testing.

These include, but are not limited to, local reactions, asthma, hives (urticaria), anaphylaxis, shock and possibly death.

I,_________________________________ , agree not to hold Northeast Ear, Nose & Throat Associates, Inc., Dr. Gergits, or his staff responsible for any adverse effect that may occur.

Patient Signature:____________________________________________ Date:___________________________

Witness:_________________________________________________ Date:_____________________________


  • Anselol (Atenolol)
  • Apo-Atenolol (Atenolol)
  • Betapace (Sotalol)
  • Blocadren (Timolol Maleate)
  • Brevibloc (ESmolol HCL)
  • Bystolic (Nebivolol)
  • Cartrol ( Carteolol HCL)
  • Corgard (Nadolol)
  • Coreg, Eucardic (Carvedilol)
  • Corzide ( Nadolol Bendroflumethiazide)
  • Emcor ( Bisoprolol fumarate Inderal (Propranolol)
  • nderide (Propanolol-Hydrochlorothiazide)
  • Innopran XL (Propanolol)
  • Kerlone (Betaxolol HCL)
  • Levatol (Penbutolol)
  • Lopressor (Metoprolol Tartrate)
  • Lopressor/Hydrochlorothiazide (Metoprolol-Hydrochlorothiazide)
  • Monocor (Bisoprolol fumerate)
  • Normodyne (Labetalol HCL)
  • Normozide (Labetalol-HCTZ)
  • Noten (Atenolol)
  • Sectral (Acebutolol HCL)
  • Tenoretic (Atenolol-Chlorthalidone)
  • Tenormin (Atenolol)
  • Timolide (Timolol-HCTZ)
  • Toprol XL (Metoprolol succinate)
  • Trandate (Labetolol HCL)
  • Visken (Pindolol)
  • Zebeta (Bispropolol fumarate)
  • Ziac (Bisoprolol)

Topically Applied beta-blockers: (eye drops, etc.)

  • Betagan (Levobunololyne (Labetolol HCL)
  • Betimol (Timolol)
  • Betoptic (Betaxolol)
  • Ocupress (Carteolol)
  • Optipranolol (Metipranolol)
  • Timoptic (Timolol)
  • Istalol (Timolol)