Patient Forms

All documents are in PDF format. 

New Patient Intake Packet (Please complete the New Patient Registration, Medical History Form, New and Established Patient Consent Form, HIPAA Form, and Advanced Beneficiary Notice of Non-Coverage (ABN) for New Patient Evaluation)

• New Patient Registration (Please complete this form to provide personal demographic, health insurance and pharmacy information.)

• New Patient Medical History Form (Please complete this form to provide thorough details of past and present medical history.)

• New and Established Patient Consent Form (Please read this form to understand our clinic policies, to be signed electronically in office)

• HIPAA Form (Please read this form to understand your health privacy rights and policies, to be signed electronically at your first appointment.)

• ABN for New Patient Evaluation (Please contact your health insurance company to complete this required form prior to your first appointment. This form contains services that may be provided and billed for at your first appointment that your health insurance may or may not cover. Increasingly health insurance companies are not paying for the level of service we provide, despite contractual agreements, this form attempts to clarify the potential cost to you directly should your insurance not pay for ANY services provided due for ANY reason or excuse.)

Policies and Other Information

• Cancellation Policy
• Antihistamines to Stay Off of Prior to Skin Testing
• Instructions for Nasal Washes

All Forms (alphabetically listed)

• Authorization to Obtain Medical Records
• Advanced Beneficiary Notice of Non-Coverage (ABN)
  • ABN for Cluster Rush Immunotherapy
  • ABN for New Patient Evaluation
  • ABN for Skin Testing
• HIPAA Form
• New Patient Medical History Form
• New Patient Registration
• Telemedicine Consent