Division of Pediatric Allergy & Immunology: Forms

The Pediatric Lung Center requires all new patients to complete several forms at their first appointment. If you would like, you may download and complete the New Patient Forms prior to your visit. Please bring them with you to your appointment.

New Patient Forms

• Patient Registration Form (English | Spanish)
• Notice of Privacy Practices (English | Spanish)
• Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) (English | Spanish)
• Consent to Treatment/Acknowledgment of Receipt of Notice of Privacy Practices (for adult patients) (English | Spanish)
• Financial Responsibility Statement (English | Spanish)
• New Allergy Patient Intake Form (English | Spanish)
• New Allergy Patient Instructions (English)

Additional Consent Forms

• Immunotherapy (Allergy Shots) Consent Form (English)
• Medical Permission Form (English | Spanish)
• Instructions for Completion of the "Authorization to Use and/or Disclose Protected Health Information" Form (English)
• Authorization to Use and/or Disclose Protected Health Information Form (English | Spanish)
• Instructions for Completion of the "Request to Access and/or Copy Protected Health Information (PHI)" Form (English | Spanish)
• Request to Access and/or Copy Protected Health Information (PHI) Form (English | Spanish)