Forms
After you schedule an appointment, you will be electronically sent forms for easy completion and submission. We prefer this method as our email is unencrypted. By emailing your forms to us, you understand and accept any risk associated with sending your information via email. Please do not email us documents containing private or financial information.
Please note for School Form request’s please click HERE and follow the directions for submission.
You may bring the completed forms to your appointment, email the documents, or fax them to the specific office (please see the location pages for that locations specific Fax number) where you’re being seen virtually or in person
However, if you understand the risks of sending your information via email and prefer emailing or bringing forms to the appointment, click the link below to download and print a PDF form.
- Email completed forms to forms@nwasthma.com.
- Please be sure to state on the subject line the LOCATION you have been or are going to be seen & the legal FIRST & LAST NAME of the patient.
- Please save the forms as a PDF file & send them as an attachment. Photos are illegible. You may use a free scanning app, such as Adobe Scan, to create PDFs using your smart device or computer.
New Patient Forms
After you schedule an appointment, you will be electronically sent forms for easy completion and submission.
Please read the following:
Useful information including a list of medications to stop prior to skin testing appointments)
COVID-19 Pre-screening Questionnaire (for your reference; does not need to be submitted)
Notice of Privacy Practices & Financial Responsibility
This updated form must be completed and updated annually. For families, you may list multiple children (and yourself) on this form. Patients over 18 years old must complete and sign the form themselves.
Consent to Discuss (for Adults, ages 18 years old and over)
This form is used for Adults (ages 18 years old and over) only and must be completed and signed by the patient.
Consent to Treat a Minor
For minors (17 years old and under), you may complete the attached form, allowing someone other than the parent/legal guardian to bring the patient in only for established-care appointments or shots. You may list multiple children on the same form. *This section does not apply to the New Patient appointment. Parents/legal guardians MUST bring the minor patient into the New Patient appointment.
Consent for Proxy Portal Access of Teen Patients
When a child turns 13, Washington state privacy laws make certain information confidential between teens and their healthcare providers and limit what information can be shared on the secure member portal for teen and proxy accounts. This privacy is designed to encourage teens to discuss issues with their providers. It also means some information cannot be automatically shared with parents and legal guardians. Patients aged 13-17 can have sole access to their EMR patient portal and can give proxy access to a parent if they wish.
For teens ages 13 to 17, parents and legal guardians can:
- Send a secure message to their teen’s primary care provider
- Refill medications that their teen’s provider has made visible online
- View their teen’s immunization records, except for the human papillomavirus (HPV) vaccine
- View their teen’s upcoming visits
- View the following health information about their teen: allergies, health reminders, and past surgical procedures, as well as most visit notes, after-visit summaries, medications, and lab test results
The only exceptions to the above are for health care information related to care that Washington state allows teens to access on their own: reproductive and sexual health care and mental health care, including substance use care. This includes some immunizations. For example, the HPV vaccine does not appear in teens’ online records once they turn 13. If your child received this vaccine before their 13th birthday, you would have seen HPV listed under immunizations until their 13th birthday.
- Send secure messages to the teen’s care team (EXCEPT providers from specialties that primarily provide reproductive or sexual health care and mental health care)
- Securely check in for appointments online
- Schedule and cancel appointments
Please see the attached document that must be signed by the minor patient and kept in the patient chart for parent proxy access. Please follow the prompts in Athenahealth for portal access.
** Important Information about the Portal **
For Short Questions and Clarifications, the most efficient way to communicate is via the portal. Please note that the portal is not a direct messaging system to the physician and is initially reviewed and triaged by nursing staff.
For more extensive conversations regarding questions about your care, it is best to make an appointment to ensure more complicated topics are given an appropriate allocated time. You may be directed to make an appointment to ensure the appropriate time and attentions can be devoted if:
- Your questions can not be answered briefly in a message (1-2 sentences).
- You have new symptoms (including new reactions to foods or drugs that have not previously been discussed).
- You have changes to a chronic condition (including worsening Asthma symptoms). We typically will not prescribe medications without a complete evaluation.
- You have questions about current news or journal articles.
- You are requesting new medications
- You need forms and/or referrals but have not been seen in the past 12 months
THE PORTAL SHOULD NEVER BE USED FOR ANY EMERGENT MEDICAL QUESTIONS OR ISSUES. FOR ANY LIFE-THREATING EMERGENCIES, CALL 911 AND GO THE NEAREST EMRGENCY ROOM. ALSO, PLEASE NOTE THAT THE PORTAL IS NOT MOINTORED ON WEEKENDS OR HOLIDAYS.
Allergy Shots or Immunotherapy (IT)
Attention shot patients:
Please ensure that you have had an appointment with your provider in the previous 6 months.
Please note that we can only refill if you are out of antigen or your antigen is near expiration.
Expired allergen immunotherapy (AIT) will not be administered to any patient.
Immunotherapy Consent Forms
Are You on an ACE inhibitor and/or Beta-Blocker and Immunotherapy?
Please complete the form below:
If you/your child is on an ACE inhibitor and starting venom immunotherapy OR has recently started a new ACE inhibitor while undergoing immunotherapy, please complete the following form.
If you/your child is on a beta-blocker and starting environmental and/, or venom immunotherapy OR has recently started a new beta-blocker while undergoing immunotherapy.
Forms:
Immunotherapy (Allergy Shots) Transfer Request Form
If you are interested in receiving your allergy shots at another medical facility, please complete (including the details of the medical facility to which you wish to transfer) and sign this form. Completed forms can be faxed to the Seattle office at: (206) 523-0724 Attn: Antigen Department, or emailed to forms@nwasthma.com. Then the supervising medical provider at that facility will return a form to us to acknowledge receipt of the antigen vials and the responsibility of supervising shot administration.
Please note: Our email is unencrypted. By emailing your forms to us, you understand and accept any risk associated with sending your information via email.
Antigen Transfer Request to another outside medical facility
If you are transferring your care and/or immunotherapy to us, please have the outside medical facility complete the following form and provide us with the information & records requested. You may not schedule your first allergy shot until after the initial new patient appointment with us.
Transfer of Care/Immunotherapy FROM outside medical facility to Northwest Asthma & Allergy Center
Medical Record Forms
Please complete and fax to the Seattle office at: (206) 527-0535 Attn: Medical Records Department, or email to forms@nwasthma.com.
Please note: Our email is unencrypted. By emailing your forms to us, you understand and accept any risk associated with sending your information via email.
Oral Challenge Consent forms
Oral Drug/Medication Challenge Consent
Consent to Treat a Minor without a Parent/Legal Guardian Present During Oral Challenge
Asthma Control Test (ACT), Test for Respiratory & Asthma Control in Kids (TRACK), & Urticaria Control Test (UCT)
Asthma Control Test (ACT)-Adult
Asthma Control Test (ACT)-Adult (Spanish)
Asthma Control Test (ACT)-For children 4-11 yrs of age
Asthma Control Test (ACT)-For children 4-11 yrs of age (Spanish)
Test for Respiratory & Asthma Control in Kids (TRACK)-For children <4 yrs of age (Although the form says <5 yrs of age, please use for <4 yrs)
School Forms
Please click HERE for more Information
Please be aware that School Form request’s can only be completed if the Patient has been seen within the past Calendar year.
Please make sure to include the Patient’s School District, Patients Date of Birth, Patients Allergens, Patient’s Weight, and the mode of delivery for Medication
If you would like your child’s school forms to be faxed to your child’s school, please sign the parent section and include the school’s name and fax number before submitting them to us. Unsigned forms can only be mailed to the patient’s home or picked up by a parent/legal guardian.
All School Form Requests outside of scheduled appointments must be dropped off at your preferred location and fees paid at the time of document drop off.
During the busy back-to-school season, please allow up to 2 weeks for completion.
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