New Patient Appointment Letter Page 3
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4Allergy and Medication Form
Today’s Date:
Patient Name:
Date of Birth:
Patient MRN:
Allergies and Sensitivities
Are you allergic to, or have you had a bad reaction to, any medication or other element? ___ Yes ___ No
If YES, please complete the section below.
Allergic to:
Type of Reaction
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Medications
Please list all the current medications you are currently taking, including those you buy without a doctor’s prescription.
Medication Name:
Medication Dose:
Number you take per day:
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