New Patient information

It's a LOT better to fill this form out at your leisure than trying to cram them in at the beginning of a visit - take your time - give us more rather than less ( spelling is NOT graded !!) If the doctors feel you would be more efficiently seen by a different type of doctor, we will advise you because we can tell with this information, if we are going to make a difference.

Your home street address *

City *

State *

Zip Code *

Best phone number *

Who is the subscriber
(Name on the insurance policy) *

Date of birth of the subscriber
(Name on the insurance policy ) *

gender *

Insurance Carrier *

Insurance ID# *

Insurance GROUP number *

Secondary Insurance *

How did you choose
this office *

Please plan on spending at least 1.5 hours in this visit. The exam rooms are small, please limit the number of people you bring to the absolute minimum - if possible, place other children with alternative care so you may - we are under severe waiting room restrictions. Feel free to bring a recording device if there are other family members who want to hear what is said.Make plans to be here a bit early - if you are late, we may have to reschedule - no kidding.

FIRST NAME: *

LAST NAME: *

DATE OF BIRTH *

Age *

gender *

Email Address *

WHICH PHARMACY DO YOU USE
WITH PHONE IF POSSIBLE
LOOK ON AN OLD BOTTLE *

WHO IS YOUR
PRIMARY CARE ? *

If we could make it simple, would you consider a virtual visit to begin the process? We may be able to get your appointment in more quickly and may be able to schedule important labs before we meet face to face? *

WHICH DOCTOR
*

Dr Lanier - specializes in nasal and respiratory allergy with sinus problems

Dr. Tierce -sees mostly children with allergy including food and skin

Do you already have an appointment
scheduled *

WHY ARE YOU COMING - THIS IS CRUCIAL.

This is an expandable box for an essay. Take your time - unload everything about your concerns and the expected result of being seen and evaluated. We are after what the FOCUS of the visit should be, a priority list ( #1 problem, #2 Problem # 3 etc) . For this emergency time, we may be able to analyze your case and order your lab work before you physically come in to the office. Let us know if you want to exercise that option.

*

0 characters

HAD PREVIOUS
BLOOD OR
SKIN TESTS
FOR ALLERGY? *

MEDICAL CONDITIONS
INCLUDING PAST SURGERIES *

Ever been on allergy
shots or drops? *

Have you ever had a
Pneumonia shot? *

HAVE YOU HAD
YOUR FLU SHOT *

USE AFRIN
SPRAYS? *

DO NASAL STEROID
SPRAYS HELP *

EVER SMOKED - how long
When did you quit? *

DO ANTI-
HISTAMINES
HELP? *

WHAT IS THE
WORSE ALLERGY SEASON *

IS THERE ALLERGY
IN YOUR FAMILY? *

INDOOR PETS *

Are your eyes *

Itchy

Burny

swollen

normal

Is your nose *

Congested

itchy

drippy

normal

Does your throat
bother you *

sore

hoarse

drainage

normal

Is your chest *

Does your heart *

hurt (chest pain)

skip beats

normal

Heartburn or reflux? *

yes

no

Are you *

sleeping poorly

anxious

mildly depressed

no issues

Is your skin *

itchy

dry

rashy

other

LIST MEDICATIONS *

LIST ANY MEDICINE
REACTIONS OR ALLERGY *