Reach Out

Todays Date

Month

Day

Year

Parent first name

Parent last name

Parent Email

Best Phone # to reach you

City/town

Name of Referral (if applicable):

Scheduling Availability

Child’s Name and Age

Child’s Allergies (food and environmental)

Has your child had an anaphylactic reaction but you did not use an EpiPen? If yes, please explain - include age, timeline and severity, how was it resolved?

If you are not sure what an anaphylactic reaction is, please describe your child’s reaction in detail.

Has your child been to the hospital for allergic reaction/observation?

Explanation of symptoms: Which symptoms took place at the same time, how many systems at once, etc. (ex: hives & vomiting after cashew)

Any other health concerns:

Please upload SKIN TEST results and RAST (blood work) numbers from allergy testing within the last year:

**Make sure you include Histamine and Saline Control for Skin Test AND Total IGE Level and any Peanut or Tree Nut Component for RAST Test**