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 New Patient Registration Forms

     

  Please arrive to the clinic at least 15 minutes prior to your scheduled appointment.  This is extremely important as you will need to sign additional forms and we will need to make a copy of your insurance card.

Prospective patients are encouraged to fill in the following forms  and return  them to our clinic by:

Fax: 719-955-9595   or

E-mail:info@stormsallergy.com

   
  Help with On-Line Forms  
   

As soon as you open a form, hit the TAB button and continue to use the TAB button while you complete the form.  DO NOT hit ENTER.

To enter your social security number or phone number, only enter numbers.  Do not enter any dashes, hyphens or parenthesis (ex:  7199556000 as a phone number entry).

Where the forms ask you for a date, there is an arrow on the right; click on that and highlight the date needed.

If you have any difficulty, please call 719-955-6000 and ask for Kim Clements in the back office.

 

 

   

Patient Registration Form

Medical History

 

 

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