Below are two options on how to fill out the form, please read each option.
Forms can be printed and hand carried.
Forms can be filled out and submitted via e-mail IF Adobe Reader used on the computer or mobile device. If PDF opens in a new window, download the form and open it in Adobe Reader. After the form is downloaded to your device, open it with Adobe Reader. In the form you will see fillable areas highlighted in a light blue. Click within this area to add information.
PDF documents on this page require Adobe Reader to view and to fill. You may obtain Adobe Reader for free from the Adobe website by clicking the icon. If you already have Adobe Reader installed on your computer, you do not need to install it again.
Please download and fill out the forms below. Bring the forms with to your new patient clinic visit. This will save time during our check-in and registration process.
REL Data Collection Form*
*This information in the Race, Language, Ethnicity Form is required by payers and government programs. You have the right to decline this information.
Prior to your appointment, please fill out the forms below and hand carry to every follow up visit. These forms will save time during our check-in process.
Child Asthma Control Test*
*CACT (To be filled out by all asthma patients 4-11 years of age)
Asthma Control Test*
*ACT (To be filled out by all asthma patients over 12 years of age)