New Patient Registration
If you’d like to download the forms instead, please click below and bring into our offices:
Miscellaneous
Medical Records Release
Allergen Immunotherapy Consent Form
Allergy Extract Quote Received
Patient Disclosure
Permission To Treat A Minor
Telemedicine Informed Consent
Credit Card Authorization
Allergy Extract Releases
OUR OFFICES
Chandler office
- 705 S. Dobson Rd. Chandler, AZ 85224-5657
- (480) 897-6992
- (480) 752-1757
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
Gilbert/Mesa Office
- 4852 E. Baseline Rd. Ste 101 Mesa, AZ 85206-4604
- (480) 346-4680
- (480) 346-4685
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
Phoenix Office
- 348 E. Virginia Ave. Phoenix, AZ 85004-1208
- (602) 266-4114
- (602) 274-5225
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
San Tan Office
- 36245 N. Gantzel Building 6 San Tan Valley, 85140
- (480) 897-6992
- (480) 584-1663
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
- 8140 E. Cactus Rd. Ste 710 Scottsdale, AZ 85260
- (480) 344-4460
- (480) 344-4465 (fax)
- (480) 839-1874 – Referrals Fax
- Schedule: Monday – Friday
Please be sure to fill out all English Forms under all Sections
he following forms are available for download in PDF format: New Patient Registration, Privacy Disclosure, Acknowledgement of Receipt of Privacy Policies, Consent for Disclosure of Information, Authorization to Release Medical Records, and Consent Form. Filling out these forms prior to your appointment will expedite your check-in process and help us serve you more efficiently at your new patient appointment. Please click on the link to each form to download it to your computer. Download the FREE Adobe Acrobat Reader to open and print the forms.
New Patient Registration Form
Privacy Disclosure/Consent
**Please note that the Acknowledgment of Receipt and Consent for Disclosure forms should be brought to your appointment. You should read the privacy disclosure and retain a copy for your records before signing the Acknowledgment and Consent forms **
OUR OFFICES
Chandler office
- 705 S. Dobson Rd. Chandler, AZ 85224-5657
- (480) 897-6992
- (480) 752-1757
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
Gilbert/Mesa Office
- 4852 E. Baseline Rd. Ste 101 Mesa, AZ 85206-4604
- (480) 346-4680
- (480) 346-4685
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
Phoenix Office
- 348 E. Virginia Ave. Phoenix, AZ 85004-1208
- (602) 266-4114
- (602) 274-5225
- (480) 839-1874 (Referrals Fax)
- Monday - Friday
San Tan Office
- 36245 N. Gantzel Building 6 San Tan Valley, 85140
- (480) 897-6992
- (480) 584-1663
- (480) 839-1874 (Referrals Fax)
- Monday - Friday