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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!

eRegistration - New Patients Only

You may now request your appointment, submit your insurance information and enter your new patient information (rather than filling out paper forms) online.

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:


              
*Required Fields
 
Patient Registration

Patient's First Name: *
Patient's Last Name: *
Best Phone#:*
(xxx-xxx-xxxx)
Best Phone Type:*
Date of Birth (MM/DD/YYYY): *
Email:
Gender: *
Race: *

Ethnicity: *

Language: *

Requested Allergist/Provider:
Preferred Contact Method:
Preferred Practice Location: *

Appointment Date
(Please give us your top 3 available dates)

Choice 1(MM/DD/YYYY): *         
Time Preference - Choice 1: *         
Choice 2(MM/DD/YYYY):
Time Preference - Choice 2:
Choice 3(MM/DD/YYYY):
Time Preference - Choice 2:
Demographic Information
Home Address:
City:
State:
Zip:

Insurance Information


Insurance Plans Accepted
Carrier:
  Plan:
ID#:
Group#:
Insurance Phone#:
Insurance PO Box#:
Policy Holder Name:
Policy Holder DOB(MM/DD/YYYY):
Patient Information
Primary Care Physician:   
First:
Last:
Primary Care Physician City:
 
Race: *
Ethnicity: *
Language: *
How did you hear about our practice?
Briefly describe the reason for this visit? *
Current Medication - Please list any and all current OTC and 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 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 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:
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 allergy/intolerance and the specific symptoms experienced:
Chemical Symptoms
Add row
Insect Allergy - Please list any insect allergy/intolerance and the specific symptoms 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 specify 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: 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:

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