New Patient Registration

Please complete all required fields prior to your first visit.

Patient Information

First Name *

Last Name *

Date of Birth *

Gender *

Marital Status

Street Address *

City *

State / Province *

Postal / Zip Code *

Home Phone *

Cell Phone *

Email Address *

Local Pharmacy

Primary Care Provider

Referred By

Reason for Consultation

In Case of Emergency

Contact Name *

Relationship *

Phone Number *

Primary Insurance Information

Please bring your insurance card to the receptionist upon arrival.

Insurance Company *

Subscriber Name *

Policy / Member ID # *

Group # *

Insurance Card (Front)

Upload an image or PDF of the front of your card.

Insurance Card (Back)

Upload an image or PDF of the back of your card.

Acknowledgments & Consent

Assignment of Benefits

I, the undersigned, assign directly to Columbia Allergy all medical benefits payable to me for services rendered. I understand that I am financially responsible for all charges incurred by me, whether or not paid by insurance. I authorize the doctor to release all information necessary to secure payment.

HIPAA Privacy Policy Acknowledgment

I acknowledge that I have been provided the opportunity to review the Notice of Privacy Practices, which provides a description of information uses and disclosures.

Financial Policy & No Show Fee Consent

I understand the financial policy, including that copays are due at the time of service. I also acknowledge the No Show fee policy (up to $200 for new patients) for appointments cancelled with less than 24 hours notice.

Digital Signature

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Type Full Name to Sign *

Date *