Greensboro 336-282-2300 | Burlington 336-227-1901 allergy@lebauerallergy.com

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NEW PATIENT FORMS – Updated August 13, 2019

Below you will find the New Patient Forms.  We suggest that you take your time filling it out and just bring it with you when you arrive for your first visit.  Please arrive a few minutes before your appointment, so that we can take your forms and put it in the computer to create your personal file.

If you are coming as a patient, please print and fill out the following form:

NEW PATIENT REGISTRATION SHEET.PDF

If you are coming as a parent or guardian for the patient, the following form will be needed.

NEW MINOR PATIENT REGISTRATION SHEET.PDF 

MEDICAL RECORDS RELEASE FROM

If you need you need your medical records released to our practice or from our practice, please use the following form to authorize the release.

MEDICAL RECORDS RELEASE FORM.PDF

 

VACCINE RELEASE FROM

If you need you need your vaccination records released to our practice or from our practice, please use the following form to authorize the release.

VACCINE RECORDS RELEASE FORM.PDF

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All forms are PDF documents and if you have problem viewing them, you can download a

Free Adobe Reader at www.adobe.com

We look forward to helping you with all your allergy and asthma needs.