Allergy Immunotherapy Patient Intake Form

Allergy Immunotherapy Patient Intake Form
Please provide your information below. Please take note that any incorrect information resulting in mismatching records in your insurance will require you to pay for our services in cash.
Date Today
MonthDayYear
Date
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Age
Gender
MaleFemale
Ethnicity
Driver's License ID No.
Insurance Policy No.
Medicare Policy No.
By signing this form, I acknowledge and confirm the following:
1. I authorize the Clinic, its agents, affiliates, or associates to conduct preliminary screening and sanitary procedures for COVID-19 prevention prior to admission to the clinic for treatment.
2. I acknowledge that should I be suspected of possible infection, I shall suspend my treatment until I get clearance resulting in negative result through a nasopharyngeal swab to detect active infection, or until my recovery should I be tested positive from COVID-19 infection.
3. I understand that the Clinic is not a medical facility capable of treating COVID-19. In this regard, I assume full responsibility for all the appropriate actions with regard to my test results.
4. I understand that it shall be my responsibility to pay for the cost and other fees for the treatment of allergy immunotherapy.
5. I understand that in case my medical or health insurance benefits does not cover the treatment by which I will undergo herein, I shall personally pay the cost of treatment in cash.
I declare and acknowledge that I am of legal age or I am represented by an individual with full legal capacity to give consent on my behalf. I have read and understood the provisions above. I declare that the information I provided above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me to my satisfaction. I am giving my full consent to the treatment and I have not been coerced, induced, or intimidated to sign this form.
Consent (without mental capacity to give consent)
I am represented by a guardian who shall give consent on my behalf
Name of Parent/Guardian
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature
Clear
Should be Empty: