Welcome

New Patients

Thank you for choosing Pienkowski, MD Clinic. If you are making your first appointment, we encourage you to fill out the paperwork below and call to arrange a date and time that best suits you.

NEW PATIENT PAPERWORK DIGITAL NEW PATIENT PAPERWORK PDF BOOK AN APPOINTMENT
A doctor is standing in front of a circle of medical icons.

Getting Ready for
Your First Appointment

Please Review Every Item to Avoid Delays or Complications

Patient Administrative Responsibilities


Your Insurance

  • Coverage – Call your insurance company to verify your coverage for allergy and immunology services
  • Verify – Verify that Dr. Pienkowski is “in-network.”
  • Ask – Ask whether your insurance requires a referral from a primary care physician to see a specialist for allergy and immunology.


Complete all New Patient Paperwork

  • Patient Information
  • Insurance Information – Making sure its current.
  • Referred by – Please make sure to provide the name of your referring physician.
  • Responsible Party Signature / Date – Do not forget to sign the patient information sheet and date it.


Allergy and Immunology Questionnaire

  • Accuracy – Be certain to fill it out completely, as doing so will assist Dr. Pienkowski greatly in assessing your condition.
  • Referred by – Please make sure to provide the name of your referring physician.
  • Signature/Date – Do not forget to sign/date the Allergy and Immunology Questionnaire.


Protected Health Information

  • Carefully read this document as required by HIPAA. Print your name, sign, and date this sheet.


Payment Policy

  • Print your name, sign, and date this form after carefully reading it.


Primary Care Physician Information

  • Please fill out this section so Dr. Pienkowski can be certain to communicate your progress to your primary care physician. In addition, let us know how you heard about us.


Parental Release

  • If you are bringing a child for treatment, print your child’s name in the first paragraph. In addition, list the people who can get medical information about your child or bring your child in for treatment. Lastly, please sign and date the Parental Release.


Patient Cancellation Policy

  • Please sign and ate the Patient Cancellation Policy. Dr. Pienkowski has a full schedule and would like the chance to offer an appointment you cannot make to another person.


Patient Medical Responsibilities


Restricted Medications Prior to Appointment

Please DO NOT take any of the following medications for at least three (3) days prior to your initial appointment:

ANTIHISTAMINES

  • Atarax, Visatril (hydroxyzine)
  • Clarinex (desloratadine)
  • Cyproheptadine (generic only)
  • Emadine (emadastine) eyedrops
  • Palgic (carbinoxamine)
  • Xyzal (levocetirizine)

OTC ANTIHISTAMINES INCLUDE

  • Allegra (fexofenadine)
  • Benadryl (diphenhydramine)
  • Dimetane (brompheniramine)
  • Claritin, Alavert (loratadine)
  • Tavist (clemastine)
  • Chlor-Trimeton (chlorpheniramine)
  • Zyrtec (certirizine)

Please do not take any over-the-counter cold preparations or steroids. This also includes any antibiotics. (Taking any restricted medications will compromise the accuracy of your allergy evaluation.) *You may continue to use inhalers and steroidal nasal sprays.


Please bring a list of the medications you take including:

  • Prescribed medication
  • Vitamins
  • Herbal Supplements


Complete all New Patient Paperwork

  • You do not wear cologne, perfumes, or body lotions. Such products are irritants, which may cause problems for other patients with breathing difficulties.
  • Wear comfortable clothing including a top that can be easily removed for your examination.
  • Please allow a minimum of 1.5 hours for your initial evaluation with Dr. Pienkowski.