Patient Forms

Welcome to Fairfield County Allergy, Asthma & Immunology Associates. Please print, complete, and bring them with you to your visit.

Authorization for Allergy Extracts (pdf)
Use this form to renew your allergy shot vials or to start allergy shots

Authorization for SLIT Immunotherapy (pdf)

Average Out of Pocket Costs of Allergy Injections  (pdf)

Office Charges (pdf)

Credit Card On-File (pdf)

Records Release From Another Doctor to FCAAIA (pdf)
Use this form to have records sent TO our office from another doctor.
You may send one copy to each office from which your are
requesting records.

Records Release From FCAAIA (pdf)
Use this form to have your records released FROM our office to
anywhere else. Be sure to sign at the bottom. You may drop the form
off, mail it, or fax it to us.


****Please check the POSTS below frequently for updated office information****

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