Barry Asman. M.D. 2550 Mosside Blvd., Ste. 202 Monroeville, PA 15146 Phone (412) 372-9234 Fax (412) 372-8671 www.DrAsman.com
Arrangements have been made for you to be seen by me for an evaluation. I look forward to
participating in your health care needs. Please download and complete these forms ahead of time to improve the efficiency of the time we will be spending together. (For your convenience please make note of the time and date of your scheduled appointment on _______________ at ______) The evaluation will typically consist of an initial consultation and examination, during which time allergy testing and pulmonary function testing will be initiated when necessary. You should be prepared to spend approximately 2 to 3 hours in my office for the first visit. At the initial visit we will discuss, in detail, the results of the evaluation, the testing results, your diagnosis and the treatment plan that will follow. Occasionally a second visit may be required. Please stop taking all allergy and cold medicine containing antihistamines or decongestants prior to your appointment. These include medications such as Actifed, Allegra, Allegra-D, Astelin, Atarax, Benadryl, Chlortrimeton, Dimetapp, Fexofenadine, Sudafed-Plus, Triaminic—which all should be stopped 3 days prior to your scheduled appointment; over the counter Claritin, Claritin-D, Loratadine, Alavert, Clarinex , Zyrtec and Zyrtec-D, Cetirizine and Xyzal should be stopped for 1 week prior to your scheduled appointment. Continue taking asthma medications, such as theophylline, inhalers, and Singulair. Also continue any prednisone, antibiotics, heart medications and/or blood pressure medications that have been prescribed. If there are any questions about medications, please call my office. Many insurance companies require special authorizations/referrals to be issued by the patient’s Primary Care Physician (PCP) before seeing any specialists (me included). Please check with your insurance company concerning this policy. If this is the case with your insurance company, please obtain this authorization/referral from your PCP BEFORE your appointment. Your referral should include a consultation and an allergy work-up/testing, as procedures to be performed at the initial visit. You can then contact your insurance company prior to your visit to my office to verify that a referral is on file. On the day of the visit, please bring: 1. These patient information forms, completed in detail.
2. Any past medical records that may be important (i.e. recent chest and/or sinus x-ray reports and/
or any recent lab work) If it’s more convenient, you may request for these to be faxed directly to the office and they will be filed in your chart to be reviewed at your appointment.
3. Insurance card(s), and any referral information, if required by your insurance company.
A parent must accompany any patient less than 18 years of age. We ask that small children/siblings of the patient, be left at home if at all possible during the consultation, so that we may concentrate our attention on the patient. I am looking forward to meeting you personally in the near future Sincerely, Barry J. Asman, M.D.
Please PRINT clearly using BLOCK CAPITALS First Name: ________________________________ Date of Birth (dd/mm/yy): _____________________ Address: _______________________________________________________________________________ _________________________________________________ Email: ________________________________ Home Tel: ____________________ Work Tel: ______________________ Mobile: ____
LIST OF PUBLICATIONS: Jean-Yves DARMON, MD Davido A, Hallali P, Darmon JY, Robinet C, Jullien JL, Corone P. Pleuropericardial cyst two-dimensio-nal echography and C.A.T. scan of a case. Coeur-Paris 1987 ; 18 : 35-8. Andrivet P, Adnot S, Brun-Buisson C, Chabrier E, Darmon JY, Braquet P, Lemaire F. Involvement ofANF in the acute antidiuresis during PEEP ventilation. J Appl Physiol 1988 ; 65 : 19