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Forms

Patient Registration
Download below, print it, and bring it completed to your appointment with us!
New Patient Registration Form
New Patient Welcome and History Form
New Patient Privacy Consent Form
Financial Policy Letter
CFAA HIPAA Policy Form

Health Records Release Authorization
Download, complete, and submit to us (in person or by fax or mail) if you wish for us to transfer any part of your medical records from our office. We want to honor your privacy by adhering to standard medical office guidelines.
Health Records Release Authorization

Food Allergy
Food Allergy Action Plan
How to Read a Food Label (from the Food Allergy and Anaphylaxis Network)

Asthma Control Test (ACT)
download below or take this test at http://www.asthmacontrol.com, print it, and bring it completed to your appointment with us!
ACT for Children
ACT for Adults

2551 N Clark St, Suite 100 - Chicago, IL 60614-6680 / Phone (773) 388-2322 / Fax (773) 388-2333
Open: Monday: 8am-6pm - Tuesday: 8am-7pm - Wednesday: 8am-6pm - Thursday: 9am-6pm - Friday: 9am-5pm
Alternate Saturdays: 8:30am-12:30pm - Closed Sunday - (Last allergy shot given 30 minutes prior to office closing)

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