New Patient Registration Form
Registration Date: Tuesday, January 27, 2026

Patient Registration Form

Personal Information

Preferred Contact Information

Information below will be the ONLY communication we will use to contact you for a COURTESY appointment reminder. Please understand it is your responsibility to know when your appointment is.

Patient Employment Information

Employer Name is required. If patient is a minor or you are unemployed please enter 'Not Available' or 'Not Applicable' in the employer name box.

Emergency Contact Information


***Please fill out ALL insurance information below in addition to providing a copy of your insurance ID card to be scanned into our EMR system. Thank you.

Primary Insurance

ID card must be presented at each visit

Secondary Insurance

Complete below for secondary insurance information

Do you have Secondary Insurance?

Parent / Legal Guardian Information

***Please fill out if patient is a minor

Is Patient Under 18yrs of age?


Acknowledgement of Notice of Privacy Practices & Patient Bill of Rights
The Allergy & Asthma Diagnostic Office has posted their "Notice of Privacy Practices" and Patient’s Bill of Rights & Responsibilities in the patient waiting room and on their website at www.allergyaway.com. I understand that upon request, I am entitled to receive a paper copy at any time. I understand the Allergy & Asthma Diagnostic Office reserves the right to change the privacy practices policy to remain in compliant with HIPAA Regulations.
Request for Service Authorization
I hereby authorize providers of the Allergy and Asthma Diagnostic Office to furnish medical services to me and consent to the performance of any diagnostic studies and medical treatment as discussed and mutually agreed to. (or, if I am executing this agreement as a parent or legal guardian of a child)
I hereby authorize the release of any medical information necessary to process any claims to my insurance carrier regarding this and subsequent visits to this office.

I certify that the information given by me in applying for payment by my insurance company is correct and that I will notify AADO with any changes in medical insurance. I authorize and request that payment of benefits by my insurance carrier be made directly to the AADO for services furnished to me or my dependent. I further understand that I may be responsible for all charges not covered by this assignment.
PLEASE NOTE: It is necessary that all requested information be completed prior to treatment. This form will need to be completed each year and when any change in information occurs. Our office will submit to your insurance carrier providing we have all the necessary information, otherwise payment in full may be requested at the time of service. ALL CO-PAYMENTS ARE PAYABLE AT THE TIME OF SERVICE; otherwise a $20.00 billing charge will automatically be added to your account. Thank You.

I have read the above certification, or it has been read to me and I fully understand these statements

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian * 

Financial Policy

If you have medical insurance, we will help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy.
We require a copy of ALL insurance identification cards and ask that you bring them with you and present them at EACH visit. (Insurances with individual cards, we must have the patient's ID card)

In addition, in an effort to prevent insurance fraud, our office requires all patients (guardians) to have a photo ID on file.

It is the patient's responsibility to secure ALL referrals if your insurance carrier requires one! If a referral is NOT in place PRIOR to your office visit, we may be forced to rescheduled your appointment. We reserve the right to charge for a visit that needs rescheduling due to non-compliance.

Please verify with your insurance carrier if we are participating providers for your insurance. Many insurance provider directories are not up to date. We must emphasize that as medical care providers, our relationship is with you, not with your insurance company. All charges are your responsibility from the date the services are rendered. It is therefore, neither our place, nor our policy to contact insurance companies to establish why they have not made payment or why payment is less than the submitted charges. If an insurance carrier has not paid within 60 days of billing, any unpaid professional fees are due and payable from you. We encourage you to ask for an estimate of the charges you will incur prior to your visit.

PLEASE NOTE: For those insurance companies with whom we have a contract, all co-payments are payable at the time of visit; otherwise a $20.00 billing fee will automatically be added to your account.
***Please be prepared to pay for High Deductible Plan charges and co-insurance at the time of service. 

  • We will submit for most insurance's providing: (we do not treat Workman's Comp, Medicare or Medicaid patients)
    • The patient information form is completely filled out and appointment & financial policies signed.
    • We have a copy of the patient's insurance identification card.
    • We are able to verify coverage with your carrier and have a complete mailing address.
    • If it is your Primary Insurance (we do not bill non-participating secondary insurance)
    • For most non-participating insurances, excluding Tri-Care, we submit claims as a courtesy to our patients however payment in full is due at the time of service. You will be reimbursed directly.
  • You will receive a billing statement for any unpaid balances, co-insurance or charges determined not covered under your policy. A $5.00 monthly billing charge will be added to all accounts over 30 days. Any disputes with balances due must be brought within 30 days of the 1st billing or they will not be considered. Accounts not paid within 3 billing cycles, will be send to collection and you will be responsible for collection fees.
  • We realize that temporary financial problems do occur and we encourage you to contact us promptly for assistance in the management of your account. Payment arrangements may be extended in the event of unusual circumstances. To avoid any misunderstandings, we invite you to discuss any financial problems with the Billing office.
ASSIGNMENT OF BENEFITS:   (REV.03-2025)
I have read, understand and agree to the AADO Financial Policy. I authorize the release of any medical information necessary to process my insurance claim(s). For participating insurances, I authorize and request payment of medical benefits directly to my physicians. I agree this authorization will cover all medical services rendered until such authorization is revoked by me. I Understand that No-Show fees are considered a non-covered service and must be paid in full prior to any further appointments being scheduled. I also understand that supplies purchased in this office are considered non-billable to the insurance company and are due at the time of service.
I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered and any fees incurred on my account. I will notify you of any changes in my health status or any changes in my insurance status. In the event my account is assigned for collection, I understand that I will be contacted by AADO collection agency of choice and I agree to pay an additional collection fee- the greater of - $25.00 fee or 30% collection fee based on the total amount due as well as any associated attorney fees.
PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *  

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *  

New Patient Appointment Instructions 

Welcome! 
 To ensure your initial visit is as productive as possible, please carefully read all enclosed materials before your appointment. If you have any questions, please contact our office prior to your scheduled visit. 

Fragrance-Free Policy 
For the safety of our patients with allergies and asthma, we ask that you abstain from wearing any perfumes, scented lotions, body sprays, or colognes to your appointment. Cigarette and marijuana smoke can also be a big trigger for sensitive lungs. We ask for you to be respectful of the sensitive lungs around you! Thank you for helping us maintain a safe environment!

Important Medication Instructions 
Some medications may need to be stopped prior to testing. There are certain medications, like antihistamines, that will affect the validity of allergy testing. Please review all cold, allergy and over-the-counter medications carefully. 

Stop the following medications 7 days before appointment: 

  • Allegra / Allegra-D (Fexofenadine)
  • Atarax / Vistaril (Hydroxyzine)
  • Axid (Nizatidine)
  • Clarinex / Clarinex-D (Desloratadine)
  • Claritin / Claritin-D / Alavert (Loratadine)
  • Cyproheptadine
  • Orange juice 
  • Pepcid (Famotidine)
  • Probiotics 
  • Semprex-D
  • Tagamet (Cimetidine)
  • Vitamins and supplements (Especially Vitamin C)
  • Xyzal (Levocetirizine)
  • Zantac (Ranitidine)
  • Zyrtec / Zyrtec-D (Cetirizine)

Stop the following medications 3 days before appointment: 

  • Astelin / Astepro / Dymista (Azelastine)
  • Benadryl (Diphenhydramine)
  • Chlorpheniramine
  • Cyclizine
  • Dimetapp
  • Doxylamine
  • Dramamine (Dimenhydrinate)
  • Patanase
  • Patanol / Pataday (Olopatadine)
  • Promethazine
  • Tavist / Tavist-D

Special Circumstances
You do not need to stop antihistamine/medications if you have concerns about a bee/venom reaction or antibiotic reactions, as these have specialized testing that would need to be scheduled for a future appointment. 

Breathing Test
If you have concerns about asthma or breathing issues, are over the age of 5, and it be deemed appropriate by the provider, you will likely be scheduled for a breathing test or a pulmonary function test (PFT). We ask that you do NOT take any oral, inhaled or nebulized bronchodilators on the day of your appointment*, including but not limited to the following: 

  • Advair (Fluticasone-Salmeterol)
  • Airduo
  • Airsupra
  • Atrovent / Combivent 
  • Breo 
  • Breztri 
  • Serevent
  • Spiriva
  • Symbicort (Budesonide-Formoterol)
  • Trelegy
  • Xopenex (Levalbuterol)

*Important: If you experience shortness of breath, wheezing, chest tightness, severe cough, please use your inhaler or nebulizer as needed for safety. 

You may continue taking any of the following medications:

  • Accolate
  • Oral or inhaled steroids
  • Singulair (Montelukast)
  • Theophyllines
  • If you are unsure about a medication, please call our office to confirm. 

What to Bring 

  • A complete list of all current medications
  • Recent bloodwork (if available)
  • Recent sinus or chest X-rays (if available)
  • Hair tie (to pull back long hair for testing purposes)

What to Expect
Your initial appointment will likely last between 2-4 hours, so we ask that you plan accordingly! Initial visits may include the following: 

  • Consultation with a provider 
  • Physical Exam 
  • Allergy Testing 
  • Pulmonary Function Test (only for those with asthma/breathing concerns or if indicated by a provider)

Additional Policies: 

  • Failure to cancel a new patient appointment with at least 24 hours' notice will result in a $150 no-show fee. 
  • If medications were not stopped as instructed, testing cannot be performed. A consultation only will occur and then a separate testing appointment will need to be scheduled.

Thank you for reviewing this information. Your health matters to us, and we look forward to caring for you.
– The Staff at Allergy & Asthma Diagnostic Office

 

 

Rev. 01.2026

PRINTED Name of Patient / Legal Guardian *
Signature of Patient / Legal Guardian *