Forms

Please download, print and complete the appropriate form(s) before you come to your appointment and bring them along to our office:​

New Patients

 

Please review our Privacy Statement:

Privacy Statement

 

Please Print, Complete, and Sign the following documents:

1) Patient and Insurance Information Sheet

2) New Patient Questionnaire

3) Acknowledgment of Receipt of Notice of Privacy Practices 

Returning Patients

 

Please review and complete this form:

Follow-Up Questionnaire

 

Patients With Asthma

 

If you have been diagnosed with asthma, please also complete one of the following three forms:

Asthma Control Test (ACT) - For Adults and Children Over 12

 

Childhood ACT  - For Children 4 to 11 Years of Age

 

TRACK (Under 4 Years of Age)-For Children under 4 

 

Patients With Eczema

 

If you have eczema, please also fill out the following form:

Eczema Assessment

Additional Forms
 
If you wish to transfer your medical records or any health-related information to us or from our office to another health care provider, please fill out the Consent For Release Of Information Form and mail the signed form to us.
Consent For Release of Information
 
If you want us to provide instructions for the emergency management of food allergy to schools or camps, please download the Anaphylaxis Emergency Action Plan form, fill and sign it and bring it along to your appointment. You may also mail or fax it to us and we will complete the form, and direct it to where you wish it to be sent.
Anaphylaxis Emergency Action Plan
 

If you are considering allergy shots (allergen immunotherapy) and wish to know more about this treatment, please read the INFORMATION ABOUT ALLERGEN IMMUNOTHERAPY (ALLERGY INJECTIONS). Once you decide that you want to start allergy shots, please print out the Consent to Recieve Allergen Immunotherapy, fill it out, and sign it, if you fully understand the information provided and have no further questions. You can bring the completed and signed consent form to our office, fax it or mail it to us. We will prepare your immunotherapy extract within one week after its receipt and notify you when you can start immunotherapy.

 

Consent to Receive Allergen Immunotherapy (Allergy Injections)

 

Exton Allergy & Asthma Assoc.

656 West Lincoln Highway

Exton, PA 19341​

For Life-Threatening Emergencies Call 911
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© 2018 by Exton Allergy and Asthma Associates