Referring Provider Portal

Fill out the form below to submit a referral for your patients.

Our team at Arkansas Allergy & Asthma Clinic appreciates the opportunity to partner with you and your patients for their care. Please fill out the following form to submit a referral for your patient. Please feel free to call us with any questions: 501.227.5210

"*" indicates required fields

Referring Provider Name*

Referring Group/Practice Name*

Your Name

Fax Number*

Office Phone Number*

Patient Name*

Patient Email

If patient is a minor, please list parent's name:

Patient Date of Birth

MM slash DD slash YYYY

Patient Phone Number*

Patient Cell Number

Preferred Location

Preferred Provider

Reason for Referral

Rhinitis/Sinusitis

Asthma

Food Allergy

Anaphylaxis

Contact Dermatitis

Drug Allergy (Specify in Complaint)

Hives

Immune Deficiency

Stinging Insect Allergy

Other Skin Rash (Specify in Complaint)

Other (Specify in Complaint)

Chief Complaint/Symptoms:

Our front office staff will contact the patient directly within two business days. Please note: a parent/legal guardian must accompany any patient under the age of 18 at the time of an initial visit. Please advise the patient that initial allergy testing lasts for two – three hours. Certain medications will need to be stopped up to five days prior to testing.

This field is for validation purposes and should be left unchanged.

SCHEDULE APPOINTMENT: CALL 501.227.5210 OR SCHEDULE ONLINE

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