New Appointment Request Form

Full Name *

Date of birth *

Phone Number *

Email *

Appointment Date *

Appointment Time

Service Type *

Select Treatment

Skin Prick Testing
Tele Visits
Review Test Results
Food Allergy (OIT)
Sublingual Immunotherapy (SLIT)
Allergy Shots
Consultation
Others
No elements found. Consider changing the search query.
List is empty.

Preferred Clinic Location *

Office Location

Vancouver, WA
Bellevue, WA
Longview, WA
Portland, OR
Beaverton, OR
Eugene/Springfield, OR
Others
No elements found. Consider changing the search query.
List is empty.

Do you currently have active insurance coverage? *

Insurance Status

Yes
Cash Pay
No elements found. Consider changing the search query.
List is empty.

Please provide your current insurance information *

Insurance Name
Insurance ID

Upload Insurance Card (Front)

Front of Insurance Card

Upload Insurance Card (Back)

Back of Insurance Card

Visit Columbia Allergy for more information