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Southwest Allergy & Asthma Center
Locations:

Plano

6100 Windcom Court,
Suite 101
Plano, Texas 75093


Serving: Plano, Frisco, Allen, McKinney, Carrollton, Richardson, Lewisville, Garland, Dallas, The Colony, Addison, Coppell, Little Elm, Celina, Prosper, Sachse, Murphy, Wylie, Rockwall, Lucas and Rowlett

(972) 398 - 3500Telephone:
(972) 398 - 3512FAX:


Denison
5012 South US HWY 75,
Suite 150
Denison, Texas 75020

Serving: Denison, Sherman, Bonham, Gainesville, Pottsboro, Van Alstyne, McKinney, Prosper, Durant (OK) and Madill (OK)

(903) 463 - 8400Telephone:
(903) 463 - 8500FAX:

McKinney
7785 Eldorado Pkwy,
Suite 500
McKinney, Texas 75070

Serving: McKinney, Frisco, Allen, Celina, Prosper, Sachse, Murphy, Wylie, Rockwall, Lucas and Rowlett

(972) 542 - 0500Telephone:
(972) 398 - 3512FAX:


Allen
In Twin Creeks Medical Center Two
1101 Raintree Cir,
Suite 200
Allen, Texas 75013

Serving: McKinney, Frisco, Allen, Celina, Prosper, Sachse, Murphy, Wylie, Rockwall, Lucas and Rowlett

(469) 656 - 1057Telephone:
(972) 398 - 3512FAX:


Green Going Green to help you breathe easier!

eForms- Follow Up Patients Only!

You may now enter your yearly update information online rather than filling out paper forms.

After completing everything below click the red Submit button at the bottom of the page to securely send us your information.




Follow Up Patient Appointment Important Items:

  1. Bring your insurance card and driver's license.
  2. Payment will be due at time of service.
  3. Do not bring any food into the office.
  4. Do not wear perfume or cologne to your visit.


*Required Fields
Online Patient Forms
 
Patient Information
First Name:*

Last Name:*

Best Phone#:*
(xxx-xxx-xxxx)
Best Phone Type:*
Date of Birth:*
(MM/DD/YYYY)
Practice Location:
Gender: *
Email:
Primary Care Physician:   
First:
Last:
Primary Care Physician City:
 
Briefly describe the reason for this visit? *
Please list any and all current Prescription medications that you take regularly or as needed for any reason- please indicate drug name, dose and dosing instruction:
Medication Dose Directions
Add row
Please list any and all current over the counter (OTC) medications that you take regularly or as needed for any reason- please indicate drug name, dose and dosing instruction:
Medication Dose Directions
Add row
Food Allergy - Please list any food allergy/intolerance and the specific symptoms experienced:
Food Symptoms
Add row
Drug Allergy - Please list any drug allergy/intolerance and the specific symptoms experienced:
Drug Symptoms
Add row
Chemical Allergy - Please list any chemical or insect allergy/intolerance and the specific symptoms experienced:
Chemical or Insect Symptoms
Add row

Immunization History

Have you received a current flu vaccination?
If yes, date:
Have you ever received the Pneumonia shot called Pneumovax?
If yes, date:
Have you ever received the Pneumonia shot called Prevnar 13?
If yes, date:
Please indicate the local Pharmacy you would like us to send your Rx if needed- please indicate pharmacy name, city, address and phone number:  *
Please indicate if you prefer liquid or tablet forms of medication if available:
Please list any NEW information regarding your health since your last visit? Indicate recent surgeries, illnesses, new diagnoses, etc.
Add row
Please list any changes in your social status since our last visit (job, residence, tobacco/alcohol use, allergen exposure):
Add row
Family History - Please list any changes in your Family History since your last visit (relative with new illnesses or disease):   
Relative Condition
Add row
Review of Systems - Please check any signs/symptoms/conditions that you currently experience:
Constitutional:
Respiratory:
 
 
GI:
 
 
Urinary:
Frequent infections:
 
 
Musculoskeletal:
Eyes:
 
 
Nose:
 
 
Chest:
 
 
Neurological:
 
Skin:
 
 
Hematology:
Endocrine:
 
 
Psychology:
 
   
HIPAA

CONSENT FOR USE & DISCLOSURE OF PERSONAL HEALTH INFORMATION AND RECEIPT OF NOTICE OF PRIVACY PRACTICES

Purpose of Consent: By signing this form, you consent to our use and disclosure of your protected health Information (PHI) to carry out treatment, payment activities, and healthcare operations (TPO).
Notice of Privacy Practices: This office will not disclose your PHI (name, address, phone number(s), social security number, date of birth, etc.) outside of the TPO without your specific authorization and consent. This office complies with HIPAA and all federal and state laws regarding the privacy of your information. The Notice of Privacy Practices is available on our website under Education. A printed copy is also available upon request.
*Required Fields
Authorization*


OPTIONAL: Disclosure of Protected Health Information
I understand that any and all medical care that I receive at Southwest Allergy & Asthma Center will be treated with the utmost confidentiality. To facilitate my medical care, I hereby authorize Southwest Allergy & Asthma Center to disclose PHI regarding my treatment and medical condition to the following individuals:
Name:
Relationship:
Date of Birth:
Phone Number:
Name:
Relationship:
Date of Birth:
Phone Number:
 
PATIENT FINANCIAL ADVISORY
 
NON-COVERED SERVICES* Required Field
 
HMO REFERRALS*Required Field
 
SELF-PAY ACCOUNTS*Required Field
 
CHANGES TO COVERAGE*Required Field
 
SERVICES RENDERED*Required Field
 

  • As a courtesy, SWAAC files claims to your insurance provider. If you are covered by insurance, it is your responsibility to understand the provisions under which you are covered.
  • Missed or cancelled appointments with less than a 24 hour notice will be subject to a $25 no-show fee. Excessive No-Shows will result in a non-refundable deposit prior to scheduling.
  • A minimum fee of $25 may be assessed to release medical records.
  • In the event that a guardian shares custody of a patient, the guardian present at the time of service is responsible for payment in full at that time. If you have a court order requiring treatment costs to be shared, it is the responsibility of the guardians to make appropriate arrangements prior to treatment..
  • All returned checks will be assessed a $25 fee.

 
 
If you are the legal representative of the patient fill out name and relationship:
Name:
Relationship:
CONFIDENTIAL VOICEMAIL AUTHORIZATION
Occasionally, it may become necessary to contact our patient(s) by telephone. In the event you are not available by phone, we will leave detailed voicemail messages regarding your/your child’s treatment. By providing your telephone number(s), you hereby grant SWAAC permission to leave detailed voicemail messages regarding your/your child’s treatment.
 
 
My Cell Phone:
My Home Phone:
My spouse's(name):Spouse's phone#:
Other(name):
Other Phone#:
TEXT/E-MAIL MESSAGING AUTHORIZATION
To better serve you, we utilize text and/or email messaging for appointment reminders and important announcements. By providing your mobile number(s) and email address, you hereby grant SWAAC permission to contact you regarding appointment reminders and important announcements.
My E-Mail Address:
My Cell Phone:

By clicking Submit Request I confirm that the above information is correct to the best of my ability and accurately reflects my/the patient's current state of health.

We look forward to providing you with personal attention and professional care.
Southwest Allergy & Asthma Center