Forms

Click a link below to download and print a PDF form.

Please note: Our email is unencrypted.  By choosing to email your forms to us, you understand and accept any risk associated with sending your information via email. Please do not email us forms containing private or financial information!

New Patient Forms

Please read over the New Patient packet for complete details and information regarding your New Patient appointment- including a list of medications to stop prior to your appointment.  These forms may be printed, filled out, and either brought in with you to your appointment, scanned and emailed to forms@nwasthma.com* or faxed to (206) 523-0724.

Financial Policy

This updated form must be completed for appointments falling after 1/2/18 and updated annually. For families, you may list multiple children (and yourself) on this form. Patients over the age of 18 years old must complete and sign the form themselves. Please send completed and signed forms to forms@nwasthma.com* or fax to (206) 523-0724.

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.  Please send completed and signed forms to forms@nwasthma.com* or fax to (206) 523-0724.

Consent to Treat a Minor

For minors (17 years old and under), you may complete the attached form, allowing someone other than 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 minor patient in to the New Patient appointment.  Please send completed and signed forms to forms@nwasthma.com* or fax to (206) 523-0724.

School Forms

Please complete the lower portion of the applicable form(s) and either email to info@nwasthma.com or fax Att: Nurse Triage at the office where you see the doctor. Click here for a list of locations with our fax numbers.

Note: We are happy to complete school forms on our patients who have seen a provider in the last 12 months.  If you would like your child’s school forms to be sent to your child’s school, please make sure you complete and sign the parent section prior to submission to us and include the name of the school and school’s fax number.  Unsigned forms can only be returned to patient’s home address or picked up by parent/legal guardian.  

During the busy back-to-school season, please allow up to 2 weeks for completion.  Prescription refills will be fulfilled within 2 business days. We are not able to email forms back to you unless you have a Portal Account.

If your child has not been seen in the last 12 months, we may not be able to complete forms without an appointment.

Allergy Shots or Immunotherapy (IT)

If you have checked with your insurance and have now decided to either start a Program of shots or want to request a renewal of your antigen, fill out this form and fax it to the Seattle office at: (206) 523-0724 Att: Antigen Department, or email to info@nwasthma.com*.

Are You on a Beta-Blocker and Immunotherapy?

If you/your child is on a beta-blocker and are starting environmental and/or venom immunotherapy OR has recently started a new beta-blocker while undergoing immunotherapy, please complete the following form. You may also need to complete the appropriate form above to order new or refill Environmental or Venom IT.

Are You on a ACE-Inhibitor and Venom Immunotherapy?

If you/your child is on an ACE-inhibitor and is starting or already receiving venom immunotherapy, please complete the following form. You may also need to complete a form to order new or refill Venom IT.

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 Att: Antigen Department, or email to info@nwasthma.com*.   Then the supervising medical provider at that facility will return a form to us to acknowledge receipt of the antigen vials and responsibility of supervising shot administration.

Medical Record Forms

Please complete and fax to the Seattle office at: (206) 527-2514 Att: Medical Records Department, or email to info@nwasthma.com*.

*Please note: Our email is unencrypted. By choosing to email your forms to us, you understand and accept any risk associated with sending your personal information via email.

Oral Challenge Consent forms

Please complete and fax to the Seattle office at: (206) 527-2514 Att: Medical Records Department, or email to info@nwasthma.com*.

*Please note: Our email is unencrypted. By choosing to email your forms to us, you understand and accept any risk associated with sending your personal information via email.