Allergy Shot Appointments

1

Allergy Shots Scheduling

Patients are required to have their epinephrine injector (Epi-Pen) with them at each visit in order to get their allergy shot(s).

2

Parent Name* This field is required.

First Name

Last Name

3

Email* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Has your insurance changed since your last office visit?* This field is required.

YESNO

6

Please upload an image of your new insurance card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

7

How many children will be getting allergy shots during this appointment?* This field is required.

8

Would you like an appointment on a weekday (Monday - Friday 8:30 am-4:30 pm) or Saturday (8:30 am-10:30 am)* This field is required.

Weekday

Saturday

9

Weekday Appointments* This field is required.Monday -Friday 8:30 AM - 4:30 PM

10

Saturday Appointments* This field is required.8:30 AM - 10:30 AM

11

Child {childNumber}'s Name* This field is required.

First

Last

12

{childName:first}'s Date of Birth* This field is required.

13

apptString

14

primaryEntry

15

ChildNumber

16

NextChildNumber

17

apptDateTime

18

After pressing Submit below you will be taken to a new form entry for child # {nextChildNumber} of {howManyChildren}