Thank you for choosing Asthma & Allergy Care of Delaware. Enclosed is a questionnaire for you to complete and
return before seeing your doctor. Your appointment is confirmed as follows:
Please complete the four pages of medical history and one page of insurance information before
appointment. You may bring the forms with you or fax them (addresses and fax numbers are below). If you have
had recent blood work, X-rays, or CT scans relevant to your current problem, please ask your doctor to fax the
reports to us. If your visit will include skin testing, please wear short sleeves. This appointment could take up to
Antihistamines interfere with allergy testing. Please discontinue them as follows:
Stop these medicines 5 days prior to your appointment:
(Allegra, Clarinex, Claritin, Zyrtec, hydroxyzine)
Stop these medicines 3 days prior to you appointment:
Any over the counter allergy/cold medicines, all PM medications containing diphenhydramine
Astelin, Patanase, Astepro Zantac (ranitidine), Axid (nizatidine), Tagament (Cimetidine)
Stop these 1 day prior to your appointment: allergy eye drops, prescription or over the counter
If you are unable to stop antihistamines because of severe symptoms, continue them and keep your
scheduled appointment. If you do continue histamines, disregard instructions you may have been given
to use EMLA cream before your appointment since we will not do skin testing.
If you are on an antidepressant please notify our office.
You may continue use of all of your ASTHMA medications and any nose spray EXCEPT
Astelin & Patanase and Astepro
PLEASE BRING YOUR INSURANCE CARD
If you are a member of an HMO such as Aetna HMO, Optimum Choice or AmeriHealth/Keystone, you will need
an authorization from your primary care physician before your visit. Your copay must be paid at the time of
Please call our office or your carrier to check on our participation with other insurance plans that are
not mentioned above.
We accept assignment with Medicare and bill all services directly to Medicare. You will be responsible for your
deductible and/or any services that are not paid by Medicare or your secondary carrier. If you are unsure about your insurance coverage, please call your insurance carrier BEFORE your visit to
. Unless you belong to an HMO or PPO group with which we participate, our contract for payment is
with you, the patient, not with your insurance carrier. If you have active insurance coverage with allergy care
benefits, we will submit a claim to your carrier as a courtesy. We will expect payment for any unpaid charges.
Payment of deductibles and coinsurance is expected at the time of service, unless other arrangements are made
in advance. Payment for services may be made by cash, personal check, MasterCard or Visa.
This is a Scent-Free office. Please refrain from using strong, odor-emitting items such as perfumes and scented
Thank you again for entrusting your asthma and allergy care to us.
Pharmacology Table 3: Skeletal Muscle Relaxants Usual Dose1,2,3,4,5 Monthly Cost6* Comments 1,2,3,4, 5 Antispasmodics-Nonbenzodiazepine Metabolized to meprobamate, an addictive sedative-hypnotic agent. Concern over abuse and dependence. Controlled substance in some states. Recommend to avoid. Evidence does not support use beyond 2-3 weeks. Withdrawal symptoms may occur with Rare h
SECTRAL 200 mg SECTRAL 400 mg ZOVIRAX 200 mg ZOVIRAX 3 % ZOVIRAX 800 mg SURGAM 100 mg SURGAM 200 mg EXACYL 1 g/10ml EXACYL 500 mg ZYLORIC 100 mg ZYLORIC 200 mg ZYLORIC 300 mg XANAX 0,25 mg XANAX 0,50 mg SURBRONC SURBRONC 30 mg AMILORIDE/HYDROCHLOROTHIAZIDE 5 mg/50 mg MODURETIC CORDARONE 200 mg CLAMOXYL 1 g CLAMOXYL 1 g