WVAAC Contact Form

Asthma & Allergy Center

Contact Form
Are You A >>>*

Current Patient at Asthma & Allergy Center and wish to contact Appt. Desk / Nurse / Provider / Extract Lab / Billing & Insurance Dept. / or Need A Prescription Refill?NEW PATIENT with a question or Wish to be called ?
Please fill and submit this easy Form OR, if you prefer, you can TEXT us at (304) 519-4057. We will answer messages received by 4 pm on work day before closing the same day, and those received in non-working hours by the end of next business day. Texts will be answered by text. Forms will be answered by phone call. All messages are HIPPA-compliant.

***REFERRING PROVIDER'S OFFICES:*** To Refer A Patient: Please go to the 'Home' page or the 'New Patient' page and click on the GREEN button. / OR / Click on the Blue 'Contact Us Today' button at the top of this page and then 'A Referring Provider' link on the 'Contact Us' page.

Patient's Name*

First NameLast Name
Are You the Above Named Patient?*

YESNO
If NO, Your Name and Relationship to Patient
IF NOT, Please Enter your Name and Relationship
Patient's Date of Birth*

MonthDayYear
Date

You wish to CONTACT*

Appointment DeskAllergy Extract LabPrescription RefillPhysician/ Provider/NurseBilling / Insurance

Your Phone Number (Preferably Cell #)*

Area CodePhone Number
New Patient Question or Wish To Be Called
Message To Appointment Desk*

0/300
Message to ALLERGY EXTRACT LAB*

.0/300
Message to Physician / Provider / Nurse*

0/200
Message to BILLING / INSURANCE Dept.*
Message Requesting PRESCRIPTION REFILL*

Please make sure you write the NAME, DOSE and FREQUENCY of the medication and the PHARMACY TEL Number. Refills can be given ONLY for meds prescribed by us, to our patients, who have not missed their last appointment and have a future appointment in our books.0/200
Your Pharmacy Phone Number*

Area CodePhone Number
Should be Empty: