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.

You may bring the completed forms to your appointment, email the documents, or fax them to the office (after clicking the link, select the location on the left) 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.

If you have difficulty completing the online forms, you may bring the completed forms to your appointment, email the documents, or fax them to the office (after clicking the link, select the location on the left) where you’re being seen virtually or in person.

Please read the New Patient packet for complete details and information regarding your New Patient appointment- including a list of medications to stop before your appointment.

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.

Allergy Shots or Immunotherapy (IT)

Attention shot patients:

  • If your office/telehealth visit for new/refill antigen is on or before December 9, 2022, your antigen will be billed to your insurance company for 2022.
  • If your appointment is after December 10, 2022 we cannot guarantee your antigen will be billed prior to January 1, 2023.
  • 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.

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.

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.

School Forms

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

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.

When emailing forms, be sure to save/attach the document as a PDF and state on the subject line the LOCATION you are going to be seen & the legal FIRST & LAST NAME of the patient.

Note: We are happy to complete school forms for 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  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.  

During the busy back-to-school season, please allow up to 2 weeks for completion. Prescription refills will be fulfilled within 3 business days. We cannot 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.