New Patients: forms we'd like you to fill out

        The following are the forms we ask you to fill out, or read and sign, when you come to the office.  THESE FORMS ARE IMPORTANT. You can save time and download them here. Please try to fax us the General Info form as soon as you fill it out - just bring the others with you, don't fax those.  To do that, you need Adobe Acrobat Reader.  Many of you have that program, but if not, you can download it for free by visiting this page: Adobe Web site.

        Please understand that many of our patients are sensitive to chemicals, so please do NOT wear ANY scented agents when you come to see us. That includes lotions, perfumes, shaving lotions, clothing scented from dryer sheets. Please be sure you smell like nothing when you come to see us!

Forms all patients need to fill out:

1. General Info

2. Insurance info: If you can fax this form to us at 505-438-1814, it will speed up check-in. It's very important that you bring in the others with you when you come. You may fax the others, since it wil help us be ready for you; you don't absolutely have to do that, but we would appreciate it.

3. HIPAA privacy statement

4. Payment acknowledgement

5. Symptom Summary

6. Drugs

7. History

8. Food History

9. See below:

If you are a female patient, you'll need this form:

Female

If you are a male patient, you'll need this form:

Male

So, if you're a new patient, you need to come in with 9 completed or signed forms (count 'em!)

Thanks very much!

[ Home ] [ Up ]

Copyright 2005 Santa Fe Center for Allergy and Environmental Medicine
Last modified: February 5, 2018