212-301-7636 SCHEDULE today Get In Touch Name * First Name Last Name Phone * (###) ### #### Text Message Communication * Message frequency varies. Message & data rates may apply. Reply HELP for support. Reply STOP to opt out. Refer to the privacy policy and terms and conditions for more information. Consent to Text Do Not Text Email * Interested In * Full Freedom Advanced Testing Other How did you find us? * Message * Thank you! New Patient Form Open Form New Patient Form - Contact Us Parent/Guardian Name * First Name Last Name Patient First & Last Name * First Name Last Name Patient Date of Birth * Patient Gender * Phone * (###) ### #### Text Message Consent * Message frequency varies. Message & data rates may apply. Reply HELP for support. Reply STOP to opt out. Refer to the privacy policy and terms and conditions for more information. I Consent Decline Email * How did you hear about us? * Choose Your Way to See Dr. Shah * Spacial Health (Remote - No Insurance) City Office (No Insurance) LI Office (Insurance) Food Allergy Summary * Include history and concerns, foods, types of reactions, prior skin tests, blood tests, component tests, BAT, prior food challenges, prior OIT/SLIT/Patch) Purpose of the Consultation * Comprehensive Diagnosis Skin Tests Blood Tests Component Tests Basophil Activation Test Oral Food Challenges Long Term Food Allergy Freedom Plan List desired long term food allergy freedom goals and interests. * For Example: Protection against accidental reactions, bite-proof freedom, Free-eating) 1. Food Oral Challenges 2. Food SLIT (Sublingual Immunotherapy) 3. Food OIT (Oral Immunotherapy) 4. Biologics + OIT 5. Combination of 1, 2, 3, 4 Other Needs - Please List * Food related anxiety, FPIES, EoE, Gluten Sensitivity, Lactose Intolerance, Fresh fruit - pollen allergy, Alpha-gal Red Meat Allergy, Seasonal Allergy, Asthma, Eczema How soon do you want to be seen? * (List days and times preferred based on your availability) Thank you! Newsletter Sign up with your email address to receive news and updates including blogs & more! Email Address Sign Up Thank you!
