Allergy Portal

Patient Information

Patient Name

Date of Birth

Phone Number

Preferred method for us to contact you:

Phone

Text

Date of last injection / drop(s)

Date of last appointment

If female - are you pregnant?

Yes

Epinephrine auto-injector expiration date

Have you started or expected to start taking a beta blocker or glaucome madication(s)?

Yes

Pharmacy Used:

Have you had a change with insurance an/or personal information.

Yes

I am requesting to reorder and continue allergy injections/sublingual drops. I understand the allergy extract that I am ordering is prepared specifically for me and it cannot be used by any other person. If I choose not to use this vial/bottle of extract, I realize that I am still financially responsible for it. I, therefore, authorize Breathe Clear Institute to bill my insurance for this extract. I also understand that I am required to pay my out-of-pocket costs such as copays, co- insurance and/or deductibles at the time of reordering. For Sublingual Immunotherapy, I understand I am required to pay at the time of reorder.

Initial here that you agree to the terms above and would like to reorder your allergy extract

I am requesting a refill of my:

Allergy shot serum (office will notify you about your out-of-pocket costs)

Sublingual drops

What date would you like to pick up your extract (must be at least 2 weeks from today)

Any comments or concerns?

Please note: If it has been more than 6 months since your last appointment with us, you will also need to see one of our providers either in person or by telehealth.

Preparation for Allergy Test

Get an Allergy Shot

Reorder Vials

Patient Information