Patient Registration Form

Welcome!

Please arrive 15 minutes before your appointment to process your paperwork and allow 1-2 hours for your initial evaluation and testing, if it is decided. Minors under the age of 18 must be accompanied by a parent or legal guardian.

Certain medications interfere with skin testing. Please review the Restricted Medications for Allergy Skin Testing (https://www.freedomallergy.com/allergy-testing-instructions.html), and call if you have any questions.

The charges for your initial visit could range from $200 - $1000, depending on services provided. We encourage you to verify your insurance coverage for your co-pay, deductible and co-insurance responsibility.

If your deductible has not been met or Reception cannot verify at the time of the appointment, a payment of $250 will be requested at check-in. This payment will include the amount of your co-pay, if your plan has one. Follow-up appointments will be $100 if the deductible has not been met.

Please bring the following items with you to your appointment:

Current insurance card and Driver’s License. If you do not have health insurance or prefer to self-pay, the first visit will be $350.
Referral, if required by your insurance plan.
Co-pay, if required by your insurance plan, must be paid at check-in.
Pertinent medical records/labs that would be helpful for your evaluation.

We request 48 hours’ notice for cancelling or rescheduling this appointment.

Our office is Fragrance-Free. Perfumes, colognes and lotions can cause severe, life-threatening asthma attacks. We ask you and accompanying family members or friends to refrain from applying fragrances.

PATIENT REGISTRATION FORM

Today's Date:

Patient Date of Birth

Patient Age:

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Gender:

Male Female

Marital Status

Married Single Divorced Other

Preferred Language:

English Other

If Other, Please Specify

Ethnicity:

Hispanic/LatinoCaucasian African American Asian Prefer not to answer

Employer:

Work Phone:

Social Security #:

Driver's License #:

Parent/Guardian Information (if patient is under 18 years of age)

Parent/Guardian Name:

Relation to Patient:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Employer:

Work Phone:

Other Information

Pharmacy Name:

Address:

City:

State:

Zip Code:

Pharmacy Phone:

Pharmacy Fax:

Primary Doctor Name:

Address:

City:

State:

Zip Code:

Doctor Phone:

Doctor Fax:

Referred by:

How did you hear about us?

Friend Family Doctor Flyer Community Event Internet Search Facebook www.oit101.org

Insurance Information

Primary Insurance Company:

Address:

City:

State:

Zip Code:

Member ID#:

Group #:

Guarantor First & Last Name:

Guarantor Date of Birth:

Guarantor’s Address

City:

State:

Zip Code:

Guarantor’s Employer:

Guarantor’s Phone:

Guarantor’s Relationship to Patient:

Secondary Insurance Company:

Address:

City:

State:

Zip Code:

Member ID#:

Group #:

Guarantor First & Last Name:

Guarantor Date of Birth:

Guarantor’s Address:

City:

State:

Zip Code:

Guarantor’s Employer:

Guarantor’s Phone:

Guarantor’s Relationship to Patient:

PATIENT ACKNOWLEDGEMENT AND AUTHORIZATION – ALL INSURANCES

Consent for Medical Care and Treatment – I hereby authorize Freedom Allergy to furnish medical care and treatment as considered necessary and proper in diagnosing or treating my/his/her medical condition.
Authorization To Release Medical Information – I hereby authorize Freedom Allergy to release any and all medical records in its possession without further authorization, (1) to any other physician or other healthcare provider in order to render patient care, and (2) to my insurance carrier(s) in order to obtain payment of financial obligations to Freedom Allergy.
Medicare or Medicare Advantage “Signature on File” – I request that payment of authorized Medicare benefits be made on my behalf to Freedom Allergy for any services furnished to me by them. I authorize Freedom Allergy to release to Medicare and its agents any medical or other information necessary to determine these benefits or the benefits payable for related services. I request that payment of Secondary benefits be made on my behalf to Freedom Allergy for any services furnished to me by them and also authorize Freedom Allergy to release to the Secondary insurer any information necessary to determine benefits payable for related services.
Authorization for Payment of Insurance Benefits – I hereby authorize payment of insurance benefits directly to Freedom Allergy. I understand that I am financially responsible for the payment of charges not covered by this assignment.
Acceptance of Financial Responsibility – I accept full financial responsibility for the payment of medical care and treatment according to Freedom Allergy.

Patient Name:

Date of Birth:

Parent/Guardian/Responsible Party

Relation to Patient

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent/Guardian/Responsible Party

Date:

HIPAA Acknowledgement and Consent Forms

I. Acknowledgement of Practice’s Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient’s Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or healthcare operations. You have the right to revoke this Consent in writing, signed by you. However, such a revocation will not be retroactive.

This Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to change the Notice of Privacy Practices as allowed by law
The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon execution of this Consent.

This consent was signed by:

Patient Name

Date of Birth

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent/Legal Representative

Date

II. Request to Receive Confidential Communications by Alternative Means

As provided by Privacy Rule Section 164.522(b), I hereby give permission for Freedom Allergy to communicate to me about appointments, lab results, and/or patient care by phone messages, texts, email, or fax.

Phone Number:

Email Address:

Fax:

Paragraph text

Signed

Date:

III. Adult Consent to Share Medical Information

I agree that the Freedom Allergy may disclose certain pieces of my health information to a person of my choosing, since such person is involved with my healthcare or payment relating to my healthcare. I give permission for Freedom Allergy to disclose the following information:

Scheduling appointments

Lab Results

All information regarding assessment, diagnosis, and treatment of my medical condition, including oral immunotherapy, immunotherapy, and other allergic treatments.

Other

If Other, Please specify

The indicated information may be disclosed either phone or email to:

Add another

Patient’s Name:

DOB:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature:

Date:

*Patient signature is required for patients who are 18 years or older, or who have emancipated minor status, or a special condition as defined by law.
*Patient can cancel this authorization in writing at any time.

Patient Intake Form

Today’s Date:

Patient Name:

Patient Date of Birth:

Reason for appointment

Please describe in your own words your main reason(s) for seeing us today:

The main problems I have are:

Eyes

Eye itching

Eye redness

Eye watering

Eye swelling/puffy eyes

Eye dryness

Need to rub eyes repeatedly

Sensitive to light

Ears

Ear itching

Ear ache/pain

Ear ringing

Ear plugging

Ear discharge

Recurrent ear infections

Hearing loss

Headache

Throat

Constant clearing of throat

Dry cough

Cough + sputum production

Throat itchiness

Sore throat

Post nasal drip

Hoarseness

Throat swelling

Chest

Chest tightness or congestion

Wheezing

Shortness of breath

Chest pain

Heartburn

Asthma

Skin

Hives/whelts

Eczema (red, scaly, itchy skin)

Giant swelling of face, eyelids, mouth, lips, tongue, or throat

Skin reaction to poison ivy/oak/sumac, metals, chemicals, or cosmetics

Recurrent skin infections

Rash

Sensitive to rubber or latex products

If Other, Please specify

List your current medications (including prescription, over-the counter, vitamins, supplements, etc):

Add another medication

Allergy Medical History

Please identify food, insect, or drug causing a reaction, describe the reaction, and date of reaction:

Have you had previous allergy testing? If yes, please describe

Yes No

Add another allergy testing

Have you had allergy shots/injections?

Yes No

Did you have any reactions to the shots?

Yes No

How long did you do allergy shots?

Still getting allergy shots?

Yes No

If yes, please describe the reaction:

Did the injections help you?

Yes No

Infection History:

How many “colds,” “flu-like illnesses,” upper respiratory tract infections (sinus/ear/throat infections), or bronchial infections have you had in the past year?

How many of the above did you have per year in the past five years?

What percentage of these infections required antibiotics?

Which antibiotics have worked the best for you in the past?

Have you had sinus surgery, tonsils/adenoids removed or ear tubes?

Yes No

Asthma History:

Age of onset of hay fever and/or asthma?

What time of day or night is the worst for your symptoms?

Have you ever been hospitalized for your asthma?

Yes No

if yes, date?

Have you had previous testing?

Pulmonologist Function Testing

Yes No

Chest X-Ray

Yes No

How often do you need to use albuterol

How many times per year have you been on oral steroids?

Home information:

How long have you lived in the South?

Do you live in an:

House Mobile home Apartment Other

If Other, Please specify:

Does your home have a basement?

Yes No

History of water damage in your home?

Yes No

How old is your home?

Do you smoke, or are there smokers in the home?

Yes No

Kind of pet(s):

Are your household pets:

Indoor

Outdoor

allowed in bedroom

Inside the House:

Heating:

Central

Electric

Gas

Wood Fireplace

Air Conditioning:

Central

In-Window

Fans

Filter system (HEPA or any other air purifier/filtration system?)

Yes No

Flooring in Main Areas:

Carpet laminate / hardwood / tile

Flooring in Bedroom:

Carpet laminate / hardwood / tile

Allergy encasement on:

Mattress/Boxspring Pillow

Humidifier?

Yes No

Family History: Do you have history of any of the following in yourself or a family member?

Hay fever/”allergies”

Self

Mom

Dad

Sibling

Other family

Asthma

Self

Mom

Dad

Sibling

Other family

Hives

Self

Mom

Dad

Sibling

Other family

Eczema

Self

Mom

Dad

Sibling

Other family

Insect sting allergy

Self

Mom

Dad

Sibling

Other family

Chronic sinus issues

Self

Mom

Dad

Sibling

Other family

Chronic bronchitis

Self

Mom

Dad

Sibling

Other family

Cystic fibrosis

Self

Mom

Dad

Sibling

Other family

Hypertension

Self

Mom

Dad

Sibling

Other family

Heart disease

Self

Mom

Dad

Sibling

Other family

Diabetes

Self

Mom

Dad

Sibling

Other family

Cancer

Self

Mom

Dad

Sibling

Other family

Anemia

Self

Mom

Dad

Sibling

Other family

High cholesterol

Self

Mom

Dad

Sibling

Other family

Arthritis

Self

Mom

Dad

Sibling

Other family

Thyroid disease

Self

Mom

Dad

Sibling

Other family

GERD

Self

Mom

Dad

Sibling

Other family

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