Child Care Policy.
The clinic understands that some of our patients have child care challenges when setting an appointment with the clinic. However, the clinic is not equipped to monitor your child while you are receiving medical treatment or while you are completing allergy testing. The clinic respectfully requests that if you bring a child to the clinic under the age of 12, you must also arrange for an adult family member or friend to watch your child in our waiting room as you are completing treatment. Your child will not be permitted to accompany you during treatment or allergy testing. Thanks for your cooperation.
Our forms library is intended for your convenience. It will save you time during your visit and avoid having to fill out forms in our waiting room. You’ll have more time to reference your prior records so that your history will be complete and thorough.
You will need to complete and submit these forms upon becoming a patient of The & Environmental Treatment Center, LLC. We suggest that you complete and sign each of them prior to your first visit to our clinic.
Move your cursor over the document you wish to download or complete on-line, and then click your left mouse button. All documents are in Adobe PDF. All documents are in Adobe PDF Format. If you do not have Abode Acrobat Reader, you may download it below.
Patient Information Update Form
Patient Information Update Form (Complete this form on-line and print.)
Please complete our on-line “Patient Information Update” form. Simply save the form from your browser to your computer. Open the file and type your information on the form presented to you on the screen. When you have completed the form, print it and bring it with you on your appointment visit.
Download Patient Information Update Form
New Patient Medical History Form
Allergy Medical History Form (Complete this form on-line, print and sign.)
If you a are new patient to our Allergy Clinic, Please complete our on-line “Allergy Medical History” form prior to your first visit. Simply save the form from your browser to your computer. Open the file and type your information on the form presented to you on the screen. When you have completed the form, click the “Print Button” on the bottom of the last page (Page 8).
Be sure to bring it with you on your first visit. Please note: To clear all the information from the form, click the reset button on the last page of the form.
Download Patient Medical History Form
Notice of Privacy Practices
Notice of Privacy Practices (Print and sign this form.)
Please read and sign this document prior to your first visit as a patient. Doing so will afford you ample time to review them and save you time during your visit.
Download Notice of Privacy Practices
Financial Policy/Legal Assignment
Notice of Privacy Practices (Print and sign this form.)
Please read and sign this document prior to your first visit as a patient. Doing so will afford you ample time to review them and save you time during your visit.
Notice of Financial Policy/Legal Assignment
Arbitration Agreement
Arbitration Agreement (Print and sign this form.)
Any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings.
Download Arbitration Agreement
Policy on Advanced Directives
Policy on Advanced Directives (Print and sign this form.)
The State of Arizona regulations require that your medical chart contains the following information. You will be asked if you have a Living Will, have assigned a Medical Power of Attorney, or designated a “surrogate” to act on your behalf.
We suggest that you read and sign each component of this document prior to your first visit as a patient. Doing so will afford you ample time to review them and save you time during your visit.
Download Policy on Advanced Directives
Insurance Plan Policy
Insurance Plan Policy (Print and sign this form.)
Please make sure that you fully investigate the coverage of your insurance plan with your insurance company before you undergo any medical services including labs, x-rays, blood tests and other diagnostic procedures. You must agree by completing this form to be solely responsible for knowing the terms and conditions of your insurance plan..
