Financially Responsible Person/Guarantor
If the patient is a minor or is not financially responsible for themselves, please fill out contact information for the person / guarantor who is financially responsible for the patient.
Release of my medical records to my personal electronic portal authorization. I understand that this health information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signing this form, I am authorizing such information to be disclosed. This authorization is effective indefinitely unless revoked in writing.
There are many sections below, please fill out the sections for which you have symptoms:
IF YOU HAVE BREATHING SYMPTOMS
IF YOU HAVE NASAL / EYE / EAR ALLERGY SYMPTOMS
IF YOU HAVE SINUS SYMPTOMS
IF YOU HAVE HIVES
OTHER ALLERGIC HISTORY
Please read carefully before hitting the "Submit" button below:
Antihistamines and certain other medications interfere with the accuracy of allergy skin testing.
The following is a list of common antihistamines. In addition, many cold/sinus preparations and eye drops contain antihistamines.
Some herbs, plants and supplements (including naturopathic/homeopathic) may also decrease the accuracy of allergy skin testing, and therefore all such products should be withheld for one week prior to testing.
Do not take for this number of days before the test date:
*Elavil (Amitriptyline) *Pamelor (Nortriptyline) *Tofranil (Imipramine) *Sinequan (Doxepin) *Desipramine
*IMPORTANT: Do not stop any medication with a * without consulting the prescribing physician.
IF you are experiencing hives or other allergy symptoms that will make you uncomfortable when antihistamines are withheld, DO NOT STOP your medication prior to the doctor’s office visit.