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Award Winning Food Allergist Dr. Atul Shah and our team have been helping Food Allergy Families for 20+ years. We have 15,000+ Success Stories and are excited to help you on your path to Food Allergy Freedom. Schedule an appointment by filling out the form below or give us a call today!

212-301-7636

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PROGRAM OVERVIEW

NEW PATIENT FORM

Please note, while our Long Island locations accept insurance, our Manhattan office does not. This is due to many of our specialized procedures not being covered by insurance plans. By opting out of insurance in the city, we ensure that we can provide you with comprehensive, uninterrupted care tailored to your unique needs without the constraints of insurance limitations.

Parent/Guardian Name

First Name

Last Name

Patient First & Last Name

First Name

Last Name

Patient Date of Birth

Patient Gender

Phone

(###)

###

####

Email

How did you hear about us?

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)