Untitled Document
 
free_wifi

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: *
Phone: (xxx-xxx-xxxx) *
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):

Physician City:

Pharmacy (Name and Location-Address):
Briefly describe the reason for your visit with the physician? *
How did you hear about our practice?
Current Medical Problems - Please list individually all current medical problems:
(Do not include resolved problems from your past)
Add row
Current Medication - Please list individually all current OTC and prescription medicines, herbal remedies: (include DOSE & DIRECTIONS)
Medication Dose Directions
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 pets?
if yes, please list each type 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?
8. Please note your current occupation (If Applicable):
9. Are you routinely exposed to birds/pigeons/dove/fowl?
Where/What?
Past Medical History - Please list individually all past resolved medical problems:
(Do not include active problems)
Add row
Allergy History - Are you allergic to any food, drug/medicine, chemical, latex or insects?     If yes, please list each individually:
Add row
Birth History - Please answer the following questions regarding the patient's birth:
1. Please check if your birth was:   or  
If premature, how many weeks?
2. Please list any other complications you experienced during delivery or after birth:
Past Surgical History - Please list individually all past surgeries, the date that they were performed, and the surgeon's name:
Surgery Date Surgeon
Add row
Infection History - Please answer the following questions regarding past infections:
Do you have a history of pneumonia?
If yes, how many episodes?
Do you have a history of Tuberculosis?
If yes, when was your treatment?
Do you have a history of being exposed to someone with Tuberculosis?
If yes, when?
Family History - Please list medical problems experienced by your family members: (Include allergy/asthma related problems)
1. Mother: 3. Sister:
2. Father: 4. Brother:
Family history of an Auto Immune disease/condition?
If yes, what?
Family history of Cystic Fibrosis or any other genetic condition?
If yes, what?
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:

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