New Patients

New Patients

Thank you for choosing Allergy and Asthma Center of Duncanville! Please complete the form below and we will contact you to schedule your first appointment.

Reason For Visit:

Patient Name:

Date of Birth:

If Patient < 18 y/o, Parent Name:

Contact Number:

Alternate Number:

Email:

If you were referred by your doctor, please provide name & phone number:

Insurance Name: (If BCBS, please include state. If Medicaid, please include type - Amerigroup, CHIPS, Traditional, Parkland Health, etc

Policy Number:

Group Number:

Insurance Customer Service Number:

If you have secondary insurance, please include this below. (NOTE: INCOMPLETE INFO CAN DELAY YOUR REGISTRATION ON YOUR FIRST VISIT)

Secondary Insurance Name:

Secondary Policy Number:

Secondary Group Number:

Secondary Insurance Customer Service Number: