Adult Patient Information Name *
Marital Status Single Married Divorced Widowed Address
* Spouse Information Name
Please list a relative or friend NOT living with the patient who could provide forwarding information (if needed)
You will need to present insurance card(s) at the time of patient's visit. Please list your insurance(s) in the correct order of coverage. If complete insurance information is not provided, all bills will be sent to the responsible party.
MEDICARE PATIENT'S ONLY: Referral Source
Whom may we thank for this referral?
Consent * Patient Instruction/Consent Sheet for Allergy Skin Testing
Skin Test: Skin tests are a method of testing for allergic antibodies. A test consists of introducing small amounts of the suspected substance, or allergen, into the skin and noting the development of a positive reaction
(which consists of a wheal, or swelling, or flare in the surrounding area of redness). The results are read 15 to 20 minutes after application of the allergen. The skin test methods used are:
Prick Method: The skin is scratched or pricked where a drop of allergen has already been placed.
Intradermal Method: This method consists of injecting small amounts of an allergen into the superficial layers
of the skin.
Interpreting the clinical significance of skin tests requires skillful correlation of the test results with the patient's clinical history. Positive tests indicate the presence of allergenic antibodies and are not necessarily correlated with clinical symptoms.
You will be skin tested to important midwestern airborne allergens and possibly some foods. These include trees, grasses, weeds, molds, dust mites, and danders and, if needed, foods. The skin testing generally takes 2 hours. Prick tests will be performed on your back and intradermal tests on your arms. If you have a specific allergic sensitivity to one of the allergens, a red, raised itchy hive (caused by histamine release into the skin) will appear on your skin within 15-20minutes. These positive reactions will gradually disappear over a period of 30-60 minutes, and, typically, no treatment is necessary for this itchiness. Occasionally local swelling at a test site will begin 4 to 8 hours after the skin tests are applied, particularly at sites of intradermal testing. These reactions are not serious and will disappear over the next week or so. They should be measured and reported to your
physician at your next visit. You may be scheduled for skin testing to antibiotics, caines, venoms, or other biological agents. The same guidelines apply.
1. No prescription or over-the-counter antihistamines should be used at least 3 days prior to the scheduled skin testing. These include cold tablets, sinus tablets, hay fever medications, over-the-counter sleeping medicines (e.g., Nytol) or oral treatments for itchy skin. Some of the names of these drugs include Actifed, Drixoral, Dimetapp, Dristan, Ornade, Benadryl, Rondec, Trinalin, Zyrtec, Claritin, Allegra, and many others. If you have any questions whether or not you are using an antihistamine, please ask the nurse or the doctor. Patients on Hismanal should not take this antihistamine for 6 weeks prior to skin tests.
2. Do not stop taking your asthma medication prior to testing
1. You may continue on your intranasal allergy sprays such as Nasacort, Rhinocort, Vancenase, or Nasalide.
2. Asthma inhalers (Intal, beclomethasone [Beclovent, Vanceril], Aerobid, Atrovent, Azmacort, Alupent, Brethaire, Albuterol [Proventil, Ventolin]) and oral theophylline (Theo-Dur, T-Phyl, Uniphyl, Theo-24, etc.) do not interfere with skin testing and should be used as prescribed.
3. Most drugs do not interfere with skin testing but make certain that your physician and nurse know about every drug you are taking.
Please let the physician and nurse know:
1. If you are taking any beta-blockers or antidepressants.
2. If you are pregnant.
3. If you have a fever or wheezing.
4. Any medications you are taking (bring a list if necessary).
Skin testing will be administered at this medical facility with a medical physician present since occasional reactions may require immediate therapy. These reactions may consist of any or all of the following symptoms: itchy eyes, nose, or throat; nasal congestion; runny nose; tightness in the throat or chest; increased wheezing;
Iightheadedness; faintness; nausea and vomiting; hives; generalized itching; and shock, the latter under extreme circumstances. PLEASE NOTE THAT THESE REACTIONS RARELY OCCUR BUT IN THE EVENT A REACTION WOULDOCCUR, THE STAFF IS FULLY TRAINEDAND EMERGENCY EQUIPMENT IS AVAILABLE.
The time set aside for your skin test is exclusively yours for which special antigens are prepared. If for any reason you need to change your skin test appointment, please give us at least 24 hours notice.
***I have read the patient information sheet on allergy skin testing and understand it. The opportunity has been provided for me to ask questions regarding the potential side effects of allergy skin testing and these questions have been answered to my satisfaction. I understand that every precaution consistent with the best medical practice will be carried out to protect me against such reactions.
Consent * Allergy and Asthma Associates, SC FINANCIAL POLICY
Please read and initial next to each of the policies below, sign and date at the bottom.
As a courtesy to you, Allergy and Asthma Associateswill handle all claim submissions to primary and secondary insurance
carriers. However, you must provide us with current copies of your insurance card(s) and notify us immediately when there
are any changesin this information. Wisconsin law dictates that health insurance carriers must process claims within 90
days of submission. If your carrier has not paid your claim within 90 days, you will be responsible for payment.
Any questions regarding your coverage, eligibility and benefits (payment) must be communicated by you directly with your
insurance carrier, as you hold the contract with that company. Pleasenote: The insured is responsible for payment on any
claims that are 1) applied to deductible or co-insurance: 2) denied; 3) partially paid, 4) partially paid specifically due to the
carrier's arbitrary determination of usual and customary rates.
If your insurance company requires a referral for your visit, you are responsible for making that determination and making
sure that referral is completed by the time of service. If this is not done, you may be personally responsible for the services
No Insurance (Self Pay):
Effective 5/1/2014 anyone without medical insurance can receive a 10% discount if the balance is paid in full at the time of the appointment. Otherwise, call the billing office after receiving your statement to set up a payment plan.
Workers Compensation and Disability:
Workers Compensation claims will be submitted on your behalf, as long ascomplete and accurate information is provided to our office. Claimsthat are denied or disputed are the responsibility of the insured and our credit terms will then apply. Any claim not paid within 60 days will be your responsibility.
Office visit copays are due at time of service. We accept cash, checks,Visa, MasterCard, American Express and Discover
Cancellation and Missed Appointments:
Appointments are an important commitment of reserved time for you and the physician/practice. Missed appointments
create interruption for staff members and other patients on the schedule. We understand that situations do arise in which
you must cancel your appointment; therefore we require that you call at least 24 hours in advance.
To cancel an appointment, please call 920-739-5213. If you do not reach the receptionist, you may leave a detailed message on our voicemail.
A "no show" is someone who misses an appointment without canceling 24 hours in advance, or who fails to show up for a
• First missed appointment: We will contact you and offer to reschedule your appointment. You will also receive a
letter reminding you of our policy.
• Any additional missed appointments: A $25.00 fee will be billed to your account. Your insurance company will not
be billed for fees associated with missed appointments. Missed appointment fees will be the sole responsibility of the patient and must be paid in full before the patient's next appointment. Patients with three or more missed appointments in a twelve month period may be dismissed from the practice.
We understand that special unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may
be waived but only with staff approval.
Our billing staff is more than willing to establish a payment plan that will accommodate your budget.
There will be a $35.00 service fee charged to your account for any NSF checks
Consent * Patient Health History Patient Name
please check all that apply
RESIDENCE: AIR CONDITIONING: BEDROOM LOCATION: REGION: HUMIDIFIER: BEDROOM FLOOR HEATING SYSTEM: BASEMENT: BEDDING/PILLOWS: Dog Cat Social History Do you currently smoke? Are you a former smoker? Are you exposed to second hand smoke? If the patient is a child, does he/she attend daycare? Past Allergy History Previous Allergy Testing? Previous Allergy Shots Did Allergy Shots Help? Past Medical History Current Medications Medications List
Medication Names/Taken for/Dosage/Frequency
Immunization History Are your routine immunizations up to date? Family History
Please indicate whether there is a history of any of the following in your family:
Mother Father Grandparent(s) Brother(s) Sister(s) Review of Symptoms
Please check any symptom you are currently experiencing:
General Eyes Ear/Nose/Throat Respiratory Cardiovascular Endocrine Gastrointestinal Musculoskeletal Genitourinary Skin Neurological Psychiatric Other relevant factslinformation to assist in your care: