We request that new patients bring the following completed forms (New Patient Registration, New Patient Questionnaire, and Office Policy) to their first office visit. For your convenience those forms are available to download and print. You may also request that forms be mailed or faxed to you. To request forms call 703-573-4440.
New Patient Form 3/11
Allergy Shot Serum Reorder Form
For allergy shot patients who take their serum out the serum re-order form is available to
download and print. Please follow all instructions on the form.
Allergy Shots Serum Reorder Form
Allergy Extract Authorization Form
Before allergy extract, for allergy shots, can be made the office must have received a completed, and signed, allergy extract authorization form. For your convenience you may download, print and complete the form below.
Allergy Extract Authorization
Completed forms may be mailed to, or dropped off at, the Fairfax office:
8318 Arlington Blvd, Suite 308
Fairfax, VA 22031
Or faxed to 703-280-4650. Authorization Form for Unattended Minors
Before an unattended minor can receive services the office must have received a completed, and signed, "Authorization Form for Unattended Minors." For your convenience you may download and print the form below.
Authorization Unattended Minors
Medical Records Release
To request medical records please complete and return the form below. Completed forms may be faxed to 703-280-4650, mailed to the Fairfax address on the form, or dropped off at the office.
Medical Records Release
Physician Acknowledgement to Administer Allergy Immunotherapy in their Office (Form)
To receive allergy injection therapy at another medical office a physician or nurse practitioner at the facility where the patient intends to receive allergy injection therapy should complete the following form documenting that certain criteria is met. Once the form is completed and returned to our office allergy injection serum will be released.
For more information on receiving allergy immunotherapy at another office please refer to the "Getting Your Allergy Injections at Another Facility" guidelines below.
Physician Acknowledgement to Administer Immunotherapy
Getting Your Allergy Injections At Another Facility
Referral/Consultation Form
If you need a referral/consultation form you may download this form, have the referring doctor complete it, and fax it to 703-280-4650 or bring it with you to your appointment.
Referral Form
|
Allergy Injection Calendars
