*Physician First Name:
*Last Name:
*Phone:
Fax:
*E-mail:
Address of Practice:
City:
State:
Zip:
Best way to reach you:	Phone   Fax   E-mail

Practice Information

Number of Physicians at Location:
Years Practicing at this Location:
Areas of Specialty:

Practice History with Allergies

Currently providing allergy testing and treatment?	Yes		No
Previous experience with RAST testing (outside lab)?	Yes		No
Do you have staff trained to draw blood?	Yes		No
Does your practice have a centrifuge?	Yes		No
Currently referring patients to allergy specialists?	Yes		No
If so, how many patients per week?

Patient Reimbursement Demographics

Allocation:

Medicare:	%
Medicaid:	%
Chips:	%
Private Pay/Insurance:	%
Total	100%

Practice Demographics

Total number of patients per week:

Patients with allergy symptoms:	%
Patients treated for allergies:	%