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I’m a New Patient

Thank you for choosing Pienkowski, MD Clinic for your allergy, asthma, and immunity care. We truly appreciate the trust you placed in us upon scheduling your first appointment. If you are about to make your first appointment, we encourage you to fill out the paperwork below and call to arrange a date and time to suit you.



Paperwork / Registration:


Getting Ready For Your First Appointment

Important : Please go through All the items below to avoid delays or complication.

Patient Administrative Responsibilities

Your Insurance. Get in touch with your insurance and take the following action:

  • Coverage Call your insurance company to verify your coverage for allergy and immunology services.
  • Verify Verify that Dr. Pienkowski is “in-network.”
  • Ask Ask whether your insurance requires a referral from a primary care physician to see a specialist for allergy and immunology.

Complete all New Patient Paperwork (NPP). NPP includes the following items:

     Patient Information Sheet: Pay careful attention to each section. Specifically, make sure each of the following items are complete.

  • Patient Information
  • Insurance Information Making sure its current.
  • Referred by Please make sure to provide the name of your referring physician.
  • Responsible Party Signature/Date Do not forget to sign the Patient Information Sheet and date it.

Allergy and Immunology Questionnaire This questionnaire is two pages and requires the following:

  • Accuracy Be certain to fill it out completely, as doing so will assist Dr. Pienkowski greatly in assessing your condition.
  • Referred by Please make sure to provide the name of your referring physician.
  • Signature/Date Do not forget to sign/date the Allergy and Immunology Questionnaire.

Protected Health Information Carefully read this document as required by HIPAA. Print your name, sign, and date this sheet.

Payment Policy Print your name, sign your name, and date this form after carefully reading it.

Primary Care Physician Information Please fill out this section so Dr. Pienkowski can be certain to communicate your progress to your primary care physician. In addition, let us know how you heard about us.

Parental Release If you are bringing a child for treatment, print your child’s name in the first paragraph. In addition, list the people who can get medical information about your child or bring your child in for treatment. Lastly, please sign and date the Parental Release.

Patient Information Release If you choose to allow ADAIC to speak with another because they are involved in your care, please be sure to list those people on this sheet. In addition, sign and date the document.

Patient Cancellation Policy Please sign and date the Patient Cancellation Policy. Dr. Pienkowski has a full schedule and would like the chance to offer an appointment you cannot make to another person.

Patient Medical Responsibilities

Restricted Medications Prior to Appointment

Do not - take any of the following medications for at least three (3) days prior to your initial appointment:

  • Antihistamines
    1. Atarax, Vistaril (hydroxyzine)
    2. Clarinex (desloratadine)
    3. Cyproheptadine (generic only)
    4. Emadine (emadastine) eyedrops
    5. Palgic (carbinoxamine)
    6. Xyzal (levocetirizine)
  • OTC Antihistamines includes
    1. Allegra (fexofenadine)
    2. Benadryl (diphenhydramine)
    3. Dimetane (brompheniramine)
    4. Claritin, Alavert (loratadine)
    5. Tavist (clemastine)
    6. Chlor-Trimeton (chlorpheniramine)
    7. Zyrtec (certirizine)
  • Over-the-counter cold preparations
  • Steroids
  • Antibiotics:
    Taking any restricted medications will compromise the accuracy of your allergy evaluation.
    You may continue to use inhalers and steroidal nasal sprays.

List of Current Medications Bring a list of all your current medication including:

  • Prescribed medication
  • Vitamins
  • Herbal Supplements

No Scented Products Do not wear any cologne, perfumes, or body lotions. Such scented products are irritants, which my cause problems for other patients with breathing difficulties.

Comfortable Clothing Please wear comfortable clothing including a top that can be easily removed for your examination.

Time Please allow a minimum of 1.5 hours for your initial evaluation with Dr. Pienkowski.