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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- New Patients Only!

You may now enter your new patient 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.


There are medications that may interfere with the accuracy of skin testing. Please click our Pre-Appointment Items below to find out what specific medications need to be withheld prior to your new patient appointment:


              

New Patient Appointment Important Items:

  1. Please consult with your primary care physician prior to stopping any of these drugs.
  2. Bring your insurance card and driver's license.
  3. Payment will be due at time of service.
  4. Do not bring any food into our office.
  5. Do not wear perfume or cologne when coming to our office.
  6. Expect approximately two hours for your initial appointment.

DRUGS TO AVOID (MINIMUM 7 DAYS)*

ANTIHISTAMINES

  • ACTIFED
  • AEROKIDS
  • AH CHEW
  • ALAVERT
  • ALDEX
  • ALLEGRA
  • ALLEGRA D
  • ANTIHIST
  • ANTIVERT
  • ATARAX
  • ATROHIST
  • BENADRYL
  • BROMPHED
  • BROMPHED PD
  • BROVEX
  • CETIRIZINE
  • CHLORPHENIRAMINE
  • CHLORTRIMETON
  • CLARINEX
  • CLARINEX D
  • CLARITIN
  • CLARITIN D
  • CLEMASTINE
  • CYPROHEPTADINE
  • DECONAMINE
  • DEXODRYL
  • DIMETANE
  • DIMETAPP
  • DIPHENHYDROMINE
  • DOXYLAMINE
  • DRIXORAL
  • DURADRYL
  • DURATAP
  • DUTUSS
  • ENDAL
  • EXTENDRYL
  • FEXOFENADINE
  • HISTEX
  • HISTUSSIN
  • HYDRAMINE
  • HYDROXYZINE
  • LORATIDINE
  • KRONOFED
  • MECLIZINE
  • MUCINEX ALLERGY
  • NALDECON
  • NALEX
  • NOVAHISTINE
  • NYQUIL
  • OMNIHIST
  • PEDIOX
  • PERIACTIN
  • PHENIRAMINE
  • PHRLEX
  • PYRILAMINE
  • RESCON
  • RONDEC

ANTIHISTAMINES CONT'D

  • RUTUSS
  • RYNTANN
  • SEMPREX
  • SUDAL
  • TAVIST
  • THERAFLU NIGHTIME
  • TRIAMINIC
  • TRINALIN
  • TUSSI0NEX
  • TYLENOL ALLERGY
  • TYLENOL COLD
  • TYLENOL PM
  • UNISOM SLEEP GELS
  • VISTARIL
  • XYZAL
  • ZYRTEC
  • ZYRTEC D

ANTIDEPRESSANTS

  • ANAFRANIL
  • AMITRIPYLINE
  • AMOXAMPINE
  • AVENTYL
  • CLOMIPRAMINE
  • DESIPRAMINE
  • DESYREL
  • DOXEPIN
  • ELAVIL
  • IMIPRAMINE
  • LUDIOMIL
  • MAPROTILINE
  • MIRTAZAPINE
  • NETAZADONE
  • NORPRAMIN
  • NORTRIPTYLINE
  • NURPRAMIN
  • PAMELOR
  • PROTRIPTYLINE
  • REMERON
  • SERZONE
  • SINEQUAN
  • SURMONTIL
  • TOFRANIL
  • TRAZEDONE
  • TRIMIPRAMINE
  • VIVACTIL

ANTINAUSEA MEDICATIONS

  • COMPAZINE
  • PHENERGAN
  • PROMETHAZINE
  • TIGAN

HERBAL SUPPLEMENTS

  • FEVERFEW
  • GREEN TEA
  • LICORICE
  • SAW PALMETTO
  • ST. JOHN'S WORT

NASAL SPRAYS

  • ASTELIN
  • DYMISTA
  • ASTEPRO
  • PATANASE

REFLUX MEDICATIONS

  • AXID
  • CIMETADINE
  • FAMOTADINE
  • NIZATADINE
  • PEPCID
  • RANITADINE
  • TAGAMET
  • ZANTAC

EYEDROPS

  • ALOCRIL
  • ELESTAT
  • LIVOSTIN
  • OPTICHROME
  • OPTIVAR
  • PATADAY
  • PATANOL
  • ZADITOR

ANTI-ANXIETY

  • ALPRAZOLAM
  • CLONAZEPAM
  • DIAZEPAM
  • KLONOPIN
  • LORAZEPAM (Ativan)
  • TEMAZEPAM
  • VALIUM
  • XANAX

MUSCLE RELAXANTS

  • AMRIX
  • CYCLOBENZAPRINE
  • FEXMID
  • FLEXERIL
  • NORFLEX
  • ORPHENADRINE

OTHER

  • CATAPRES
  • CHLORPROMAZINE
  • CLONIDINE
  • HALDOL/ HALOPERIDOL
  • PARLODEL
  • SEROQUEL (Quetiapine)
  • TOFRANIL (bed wetting)
  • THORAZINE
 
THESE MEDICATIONS ARE OK TO USE:

NASAL SPRAYS

  • AFRIN (OXYMETAZOLONE)
  • ATROVENT
  • BECONASE
  • FLONASE
  • FLUTICASONE
  • NASOCORT AQ
  • NASONEX
  • PHYENYLEPHRINE
  • RHINOCORT
  • VICKS NASAL SPRAY
  • VERAMYST

DERM DRUGS

  • ATOPICLAIR
  • ELIDEL
  • MIMYX
  • PROTOPIC
  • STEROID CREAMS

RESPIRATORY DRUGS

  • ACCOLATE
  • ADVAIR
  • ALBUTEROL
  • ATROVENT
  • FLOVENT
  • PULMICORT
  • SINGULAIR
  • THEOPHYLLINE
  • VENTOLIN
  • XOPONEX

MEDICATIONS FOR ADHD

  • CYLERT
  • PAXIL
  • PROZAC
  • RITALIN
  • WELLBUTRIN
  • ZOLOFT

DECONGESTANTS/ EXPECTORANTS

  • CARBAPENTANE
  • DELSYM
  • DEXTROMETHORPHAN
  • DURATUSS
  • DURAVENT
  • ENTEX LA, PSE
  • GUAIFENISEN
  • HUMABID
  • PHENYLEPRINE
  • RESCON GG
  • RESPI-TANN, RESPI-TANN G
  • ROBUTUSSIN PD, DM
  • TRIAMINIC YELLOW
  • SUDAFED PE
  • Z-COF DM

REFLUX MEDICATIONS

  • ACIPHEX
  • NEXIUM
  • OMEPRAZOLE
  • PREVACID
  • PRILOSEC
  • PROTONIX
  • ZEGERID

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

Last Name:*

Best Phone#:*
(xxx-xxx-xxxx)
Best Phone Type:*
Alt. Phone#:
(xxx-xxx-xxxx)
Alt. Phone Type:

Date of Birth:*
(MM/DD/YYYY)
Practice Location:
Gender: *
Email:
Primary Care Physician:   
First:
Last:
Primary Care Physician City:
 
Race: *
Ethnicity: *
Language: *
How did you hear about our practice?
Briefly describe the reason for your visit with the physician? *
Current Medication - Please list any and all Current OTC and Prescription medications that you take regurlarly or as needed for any reason- please indicate drug name, dose and dosing instruction:
Medication Dose Directions
Add row
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 the mail-in Pharmacy you would like us to send your long term recurrent 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:
Past Medical History - Please list any resolved problems that are no longer active:
(Do not include active problems)
Add row
Current Medical Problems - Please list any active medical problems that have not resolved:
Add row
Past Surgical History - Please list the type of surgery, date, and surgeon's first and last name:
Surgery Date Surgeon
Add row
Family History - Please list any close relative(s) (mom, dad, brother, sister) that suffers from any asthma, allergies, skin conditions, autoimmune, and/or immune difficiency states:   
Relative Condition
Add row

Immunization History

Are your vaccinations up to date?
If no, please explain why not?
Have your received this year's annual flu shot?
If yes, when?
Have your ever received the Pneumonia shot called Pneumovax?
If yes, when?
Have your ever received the Pneumonia shot called Prevnar 13?
If yes, when?
Food Allergy - Please list any food allergy/intolerance and the specific sypmtoms experienced:
Food Symptoms
Add row
Drug Allergy - Please list any drug allergy/intolerance and the specific sypmtoms experienced:
Drug Symptoms
Add row
Chemical Allergy - Please list any chemical allergy/intolerance and the specific sypmtoms experienced:
Chemical Symptoms
Add row
Insect Allergy - Please list any insect allergy/intolerance and the specific sypmtoms experienced:
Insect Symptoms
Add row
Social History - Please answer the following questions regarding your social/occupational status:
1. Do you currently smoke?
If yes, do you smoke every day?
If yes, how long?
2. Do you live with someone that smokes?
If yes, how long?
3. Do you have a history of smoking in the past?
If yes, how long?
4. Are you routinely exposed to animals/pets?
if yes, please list each type of animal/pet individually:
Indoor Pet?
Add row
5. Are you exposed to mold?
If yes, where?
6. Are you exposed to fumes/strong odors?
Where/What?
7. Are you exposed to chemicals?
Where/What?
9. Are you routinely exposed to birds/pigeons/dove/fowl?
Where/What?
8. Please note your current occupation (If Applicable):
Infection History - Please answer the following questions regarding recent past infections:
Number of ear infections in the last 12 months:Treated with antibiotics?
Number of sinus infections in the last 12 months:Treated with antibiotics?
Number of episodes of sorethroat in the last 12 months:Treated with antibiotics?
Number of episodes of pneumonia in your lifetime:Treated with antibiotics?
Number of episodes of bronchitis in your lifetime:Treated with antibiotics?
Other major infections in your lifetime and approximate date experienced/treated:
Infection Date
Add row
Please list any oral or systemic steroids that you have received in the last year with the approximate date and condition for which the steroids were prescribed:
Steroid Date Condition
Add row
List of antibiotic names used in the last 12 months:
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:
 
   
If you are experiencing any other signs/symptoms/conditions not listed above please list individually below:
Add row
Additional comments you would like to share with the allergist:
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: Our office promises not to 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. Our office complies with HIPAA and all federal and state laws regarding the privacy of your information. A copy of our Notice of Privacy Practices document is posted on our website in the helpful links section and a copy is available to you at any time at our office.
*Required Fields
Authorization*


OPTIONAL: Disclosure of Protected Health Information
I understand that any and all medical care that I receive at Southwest Allergy and Asthma Center will be treated with the utmost confidentiality. To facilitate my medical care, I hereby authorize Southwest Allergy and Asthma Center to disclose PHI about 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.
  • 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