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1 Atlergy, Asthma and Clinical mmunology Fort Worth Allergy and Asthma Associates Lovell Avenue Fort Worth, TX 7617 (817) 1s-55 FAX (81'1) Robert J. Rogers, M.D., P.A. Susan R. Bailey, M.D., P.A. Andrew D. Beaty, M.D. New Patient nformation Welcome to Fort Worth Allergy and Asthrna Associates! Your appointment is with Dr on at f you are paying for this visit without insurance, your visit will cost approximately $165-$8, depending on whether allergy testing is needed or not. You will be able to discuss your testing options with your doctor at the time of your visit. We expect payment at the time of service. f you need a payment plan, please contact us prior to your visit to arrange a plan. Your health insurance coverage is a contract between you and your insurance company. f your insurance plan requires you to have a referral, it is your responsibility to obtain the referral prior to your appointment. f a referral is required, please contact your primary care physician's office as soon as possible, since it may take up to a week to process the referral. f you come for an office visit without a current referral, you will be asked to reschedule your appointment or to pay out of pocket for the visit. You will need your insurance card at the time of your visit. f your insurance plan has a co-pay, you will need to know that amount. For some insurance plans, office visit co-pays are higher for specialist visits (we are specialists) than for primary care visits. We will collect your co-pay at the time of service. f you have not met the deductible for your insurance, we will collect payment for the service provided. Please read the attached t-rnancial policy carefully, and feel free to ask our staffifthere are any questions. PLEASE DO NOT MAL THESE FORMS BACK TO THE OFFCE. YOU SHOULD COMPLETE THE FORMS AT HOME AND BRNG THEM TO US AT THE TME OF YOUR APPONTMENT. F YOUR FORMS ARE NOT COMPLETED AT THE TME OF YOUR APPONTMENT, T MAY BE NECESSARY FOR YOU TO RESCHEDULE. Do not hesitate to call if you have any questions. We look fbrward to meeting you. Diplomates of the American Board of Pediatrics ancl the American Board of Allergy and lmmunology

2 FORT WORTH ALLERGY & ASTHMA ASSOC. 599 Lovell Ave Fort Worth, TX 7617 (81 7) 5-s5 Fax (8 7)7-466 Appointment Date: Doctor: Patient's Name (Last) Address Home Phone Social Security#_ Daytime Phone (First) Oc (M)_ State _Zip_ Birthdate Sex Marital Status Referring Physician & Phone Number Relatives who are also nsurance nformation (This section rnust be completed ilyou want us to frle your insurance, do not fill out if you have an indemnity plan or an insurance plan which we are not contracted) nsurance Co Employee who carries insurance Member # Social Security Number of nsured Relationship to patient Parent/Guarantor (if minor) Address (if different from patieng_ City Daytime Phone State Relative not living with you Address _Empl zip-employer_ Cell Referral Required? Yes/t,lo Birthdate # Phone Relationship_ Payment for Servicc. understand am responsible for payrnent of all fees for service rendered by Fort worth Allergy & Asthma Associates. f applicable, authorize direct payment of medical benefits to Fort worth Allergy & Asthma Associates. f insurance denies a claim for any reason, or if deductibles, copays and co-insurance appry, agree to pay any outstanding balance due beyond insurance^ Signature (or guarantor, if minor) Release of nformation. f applicable. authorize the release of any medical information necessary ro process any insurance clairns. Signature (or guarantor, if

3 '*;.w FORT WORTH ALLERGY AND AST-MA ASSOCATES Appointment PATBYT DATA BASE Name: Age: Date:_. CHEF COMPLANT: A. The most troublesome symptoms you have are. PRESENT HSTORY: A. How long have you had tle worst symptom? B. Which seasons seem to affect you the most? SPzuNG SUMMER FALL WNTER C. What motivated you to seek consultation at this time?. SYMPTOMS Nasal/Throat Svmptoms Nasal Congestion Watery Discharge Thick Drainage Post nasal drainage Sneezing tching nose Sore throat Eve Svmptoms Watering tching Tearing Redness Chest Symptoms Shortness olbreath Wheezing Chest tightness Cough Worse at night? Worse at exercise? Phlegm f applicable. how many: Ernergency room visits for asthma? Hospitalizations for asthma? CU Ventilator Pneumonia? -o$ s" st.&- $ 4 -V -Y' t" o' ^)" \\ {.'.- Y Awakened from sleep because of asthn\a Nights/rnonth Nr.rmber of missed school or workdays in the past l months due to: asthma nasal symptoms sinus infections # of days/month that asthma interi'eres with work, school, or home activities n J J J Clear Colored a"s" Skin Symptoms tching Hives Dry skin Swelling Frzema V. MEDCATONS What are your current medications? Name: Helped? Rescue inhaler use in past month: # of days*--. *."#r.d Other medications you've used for any of your allergy symptoms fn the past, includine over the counrer nas_al drop_s and eye.drops such as Visine or Naphcon A, and/or herbal therapies. V. AGGRAVATNG FACTORS: Nose Chest Eyes Skin Exercise Cold air lnfections Weather changes Cigarette smoke Laughing Enrotional stress Grass mowing Dust exposure Foods Aninrals (Which animals) Mold (mildew) Menstruation Pregnancy Other V. NSECT.Sru^/G.S 'lave you ever had a severe reaction to an insect bite or sting? Which insect? Describe the reaction:

4 W. HEADACHE HSTORY: (cutwer only l/ headoches arc a major prcblem) How long have you had them? Where does it hurt? Can you predict when they are coming? Do they make you nauseated? Do they make you vomit? Can you think of anything that brings them on? Any warning symptoms (flashing lights, dots...)? What does it take to get over one? Flave you seen a neurologist? Name the medications used to treat this in the past V. MEDCAL HSTORY: Please list all other medically diagnosed conditions List any previous surgeries '\..r Does anvone in vour immediate familv (mother- father grandpaient, sist-er, brother) have any bf the following: Hay fever Sinus problems Asthma Emphysema Bronchitis Enzema Migraine Which member X. E NVRONMENTAL HSTO RY: Home: year built Urban - Suburban fue there mold (mildew) problems? Type Nasai polyps Rural--- Who smokes, where, and how long in your household? (including ioursel What pets do you have, and where are they kept? Are pets allowed in the patient's bedroom? X. PAST ALLERG Y WORKUP/TREATMENT: Have you been treated for allergy before? Was skin testing done? When? Which doctor? Results: Was blood testing (for allergies) done'7 Results. Have you been on allergy immunizations? Where was this done? (Homdoffice) How long were you immunized? What results did you get? (None, some, cured) Would you consider it again? X DRJG ALLERGES: Drug Reaction Date What fype of mattress does the patient sleep on? Boxspring Waterbed-=- -" Pillow: Synthetic Feather,-"-.,'--- Foam s the bedroom carpeted? ls there heat and air conditioning? Central Other -.--.*-,, HEPA filters- Electrostatic fi lters *. Day care School grade _- - Sports _. _._._ Wood burning stove Are there school or work allergy triggers? f so, what? Occupation Location X. WHO S YOUR PERSONAL PHYSCAN? X. WHO REFERRED YOU TO US? Please use this space to expand on aoy portions ofyour history not covered in the above questions

5 Allergy, Asthma and Clinical mmunology Fort Worth Allergy and Asthma Associates Lovell Avenne Fort Worth, TX 7617 (817) ts-s5 FAX (817)'7-466 Robert J. Rogers, M.D., P.A. Susan R. Baitey, M.D., P.A. Andrew D. Beaty, M.D Payment for all services is due at the tirne of service. Payment may be made by cash, personal check, Visa, MasterCard, or Discover. PERSONAL HEALTH NSURANCE Co-pays, co-insurance fees, and deductible fees should be paid at the time of service. We will attempt to determine what should be paid based on available information at the time of your visit, but up-to-date infonnation is not always available, and adjustrnents rnay be needed based on the response from your insurance company. The insurance contract is between the patient and the insurance company, and not the physician. The amount paid by the insurance company may not fully cover the amount charged for the service. The ultimate obligation forpayment of the charge for services rests with the patient. We will provide whatever information is needed to assist in obtaining proper insurance reimbursement. HMO. PPO, POS, MEDCARE OR MEDCAD NSURANCE For any of these types of insurance, we will accept the co-payment amount at the time of service and file a claim with the insurance provider. t is the responsibility of the patient to inform our office of the insurance carrier and to obtain any required referral or authorization numbers from the primary care physician one week prior to the appointrnent. f our physician recommends a test, service or treatment that is not covered by the insurance plan, the patient will be informed of the reason for the recommendation and the expected cost. f the patient agrees, payment for the service will be the responsibility of the patient. FEE FOR MSSED APPONTMENTS There will be a $5 charge for missing a scheduled appointment without notiffing our office within one working day of the appointment time. have read the financial FNANCAL POLCY policy, and agree to the terms stated therein which are applicable to my insurance situation. accept full responsibility for my account and my co-insurance requirements. Signed Date: Diplomates of the American Board of Pediatrics and the American Board of Allergy and lmmtmology

6 Alergy, Asthma and Clinical mmunology Fort Worth Allergy and Asthma Associates Lovell Avenue Fort Worrh. TX 7617 (8 7) 5-55 FAX (817) Roben.l. {ogers. M.D., P.A. Susan R. Bailey, M.D., P.A. Andrew D. Beaty, M.D. Authorization for Communication of Protected Health nformation to Family Members or Friends i-r authorize Fort Worth Allergy and Asthma Associates to discuss protected health information about rlre witl-r the following: Name relationship phone number Name relationship phone number Name relationship phone number! authorize Fort Worth Allergy and Asthma Associates to leave messages that included protected health information on my phone numbers as listed below: E want to opt out of the automated appointment reminder system. Printed name of Patient/Authorized ndividual Signature date This authorization shall remain in effect until revoked in writing by the patient or authorized individual Diplomates olthe Arnerican Board olpediatrics and the American Board of Allergy and mmunology

7 rstate Ma Ave Locke Ave Lovell Ave Fort Worth Allergy and Asthma Associates 599 Lovell Avenue (817) 1s-ss! (ooe, 't c : P c lnterstate

8 TOR' WOR' T ALLERGY & ASTHMA ASSOCAT'ES MEDCATONS THAT MAY NTERFERE WTH SKN TESTNG These medications must be avoided for at least DAYS prior to skin testing. unless otherwise specified. Some medications must be avoided for at least 7 DAYS and are marked with an (*). lf you are toking a medication on this list for o chronic condition, such os depression, do not stop that medicotion without first checking with us to determine if it is sofe to do so. Coll Dr. Rogers (ext. 11)Dr. Bailey (ext. 77)Dr. Beaty (ert. 16). Do not stop osthma medications. Do not stop nosal sproys. A Any over the counter medication with the word "Allergy" Acetaminophen PM Actifed AccuHist-LA Advil PM Aerokid Alavert Alka-Seltzer Plus *Allegra, Allegra D AllerRX PM Allergy eye drops of any kind Alprazolam Amitriptyline Anafranil Antivert Astelin nasal spray Astepro nasal spray Atarax Atrohist Plus Axid Azelastine nasal spray or eye drops E Benadryl Bepreve eye drops Bromfed, Bromfed PD Brompheniramine Brovex D g Ca{adryl lotion Celexa Chlorpheniramine Chlortrimeton Cimetidine Citalopram *Claritin, Claritin ) *Clarinex Clemastine Clomipramine Contac Clproheptadine D Deconamine Desipramine Desloratadine Desyrel f)imetane Dimetapp Dimenhydrinate Diphenhydramine *Doxepin Doxylamine Dramamine Dristan decongestant f)rixoral Duratapp, Duratapp PD Duravent DA Dymista nasal spray E Elavil Elestat eye drops Emadine eye drops Endal HD Excedrin PM n Famotidine *Fexofenadine Fluoxetine Fluoxamine H Histex CT, HC or PD "lydroxyzine buprofen PM mipramine K Ketotifen eye drops! Lexapro Levocetirizine Livostin drops *Loratadine *Avoid for 7-1 D*ys

9 M Meclizine Midol Montelukast (do not take 4 hours before testing) N Naldecon Nefazodone Nolahist Norpramin Nortriptyline Novafed Nyquil, Nyquil Cough o Optimine Optivar eye drops Ornade E Pain medicines with '(PM" Palgic Pamelor Paroxetine Pataday eye drops Patanase nasal spray Patanol eye drops Paxil PBZ-SR Pediacare Cough Cold Pediacare Night Rest Pepcid Periactin Phenergan Phenhydramine PM formula of all pain medications Polyhistine CS, DM, or D Promethazine Protriptilene Prozac a Quadra-Hist D QDall, QDall AR R Ranitidine Rescon Rescon Jr or MX Rondec DM Ru-Tuss Rynatan Ryna 1 Rynatuss S Semprex D Sertraline *Sinequan *Singulair (do not takie 4 hours before testing) Sinulin Sleeping pills containing PM (diphenhydramine) Sudal l Surmontil Tagamet Tanafed Tavist, Tavist D Teldrin Temaril 1'ofranil Trazodone Triaminic ''rimipramine Trinalin 'ussi-1 Tussionex Tylenol Allergy Tylenol PM v Vistaril Viravan T, S, or DM Vivactil x Xanax Xyzal Z Zaditor eye drops Zantac Zoloft Zanalon creffn Zyrtec, Zyrtec l) HERBS Licorice Green tea Saw Palmetto St. John's Wort Feverfew *Avoid for 7-1 days 4--15