New Patient Packet

New Patient Packet
First Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Sex:*

MaleFemalePrivate
SSN*
DOB*

MonthDayYear
Date
Age*
Email
example@example.com
Employer*
Business Phone
Please enter a valid phone number.
Marital Status*

SingleMarriedWidowedDivorced
Parent/Guardian Name(s) (If patient a child)
Spouse Name
Spouse Employer
Spouse Phone
Please enter a valid phone number.
Spouse DOB

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Relationship to Emergency Contact*

Insurance Information

Please present insurance card to receptionist.
Primary Insurance
Insurance Provider*
Policy Number*
Policyholder Name*

First NameLast Name
Policyholder DOB*

MonthDayYear
Date
Policyholder Phone Number*
Please enter a valid phone number.
Policyholder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder Employer*
Do you have secondary insurance?*

NoYes
Insurance Provider*
Policyholder Name*

First NameLast Name
Policyholder DOB*

MonthDayYear
Date
Policyholder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder Phone Number*
Please enter a valid phone number.
Policyholder Employer*
Authorization
I hereby authorize the Clinic to furnish any relevant information to insurance carriers concerning this illness/ accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by insurance. I agree to pay copays at time of service and all other insurance balances within 30 days of receiving a statement.
Responsible Party Signature:*

Clear
DateTime

RELEASE OF PROTECTED HEALTH INFORMATION FORM
I give permission to the physicians and staff at Allergic Diseases, Asthma & Immunology Clinic, P.C. d/b/a Pienkowski, M.D. Clinic , to discuss my protected health information with the following people I have listed below. List family members and/or friends whom you permit to have access to your health information because they are involved in your care or payment related to your healthcare.
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Signature*

Clear
DateTime

PATIENT CANCELLATION POLICY FORM
We strive to provide nothing but excellent patient care. Patient satisfaction and wellbeing is our ultimate concern. In order to provide high-quality service to all new and established patients, it has become necessary to establish a patient cancellation policy.

Patients are obliged to attend their scheduled appointments. When you miss an appointment without advanced notice, the Clinic never even gets the chance to offer that appointment time to another patient in need of treatment.

We understand that you may need to miss a scheduled appointment from time to time. Just do us a favor and give us at least 24 hours notice if you must cancel your appointment. Giving us advanced notice will allow the Clinic to offer that appointment time to another patient.

Should you need to cancel an appointment after the office is closed – weekends and holidays, inclusive – we request that you call the office and leave a message. Otherwise, please make appointment cancellations during our regular business hours. If you miss an appointment without 24 hours notice, there will be a fee assessed. This fee will be due when you are billed or at your next appointment, whichever event comes first. This fee is the sole responsibility of the patient and will not be billed to your insurance company.

THE MISSED APPOINTMENT FEE IS $20.00

If you have an unavoidable emergency pop up, please let us know as soon as possible. We have no intention of punishing patients with a missed appointment fee for emergency situations entirely out of their control. In order to better serve you, we have an automated appointment reminder system in place.

Our hope is that the automated reminder will help everybody keep their appointments and receive the care they need. Please be sure to specify a contact number at which you check messages regularly.

We sincerely thank you for working with us to provide you the best possible care.
I acknowledge that I understand the meaning and purpose of the above information.*

Clear
DateTime
Should be Empty:

	Yes	No
Indoors
Outdoors
At Home
At work
Morning
Afternoon
At night
Weather change
Rainy weather
Windy weather
Dry weather
Hot day
Cold day
Exercise
Sweating
Anger
Nervousness
Eating
Air Conditioning
Barn area
Damp areas
Hay
Mowing lawn
Dusty environments
Air pollution
Animals
Cooking odors
Smoke
Soap Power
Insecticides
Paint fumes
Perfumes
Cosmetics
Perms
Newspaper
Wool
Road dust
Milk
Milk products
Wheat products
Nuts, beans, seeds
Chocolate
Meat
Fish
Fruit
Vegetables
Beer
Cheese
Mushrooms
Wine
Asprin
Drug allergies
Chemical allergies

Insurance Information

Primary Insurance

Authorization

ALLERGY + IMMUNOLOGY QUESTIONNAIRE FORM

Have you seen an allergist or other physician for this condition previously?

About your living conditions:

HIPAA NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM

Primary Care Physician

PARENTAL RELEASE FORM

PAYMENT POLICY FORM

RELEASE OF PROTECTED HEALTH INFORMATION FORM

PATIENT CANCELLATION POLICY FORM