Book An AppointmentPatient RegistrationPatient Privacy ConsentAllergy Questionnaire - Part 2Book An Appointment Name First PhoneEmail ServicesCritical Care & Haemodynamic Monitoring Sleep Medicine Pulmonary Medicine Calendar October 2026 Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 October 5, 2026 1:35 AM October 6, 2026 1:35 AM October 7, 2026 1:35 AM October 8, 2026 1:35 AM October 12, 2026 1:35 AM October 13, 2026 1:35 AM October 14, 2026 1:35 AM October 15, 2026 1:35 AM October 19, 2026 1:35 AM October 20, 2026 1:35 AM October 21, 2026 1:35 AM October 22, 2026 1:35 AM October 26, 2026 1:35 AM October 27, 2026 1:35 AM October 28, 2026 1:35 AM October 29, 2026 1:35 AM Patient Registration Dutchess Pulmonary Patient Registration formFIRST-MIDDLE-LAST NAMEBIRTHDATEACCOUNT # (OFFICE USE ONLY)STREET ADDRESS (APT#) CITY, STATEZIPCODEMARITAL STATUSEMAIL ADDRESS (FOR APPT. REMINDERS)HOME NUMBERCELL:WORK:SEX RACESOCIAL SECURITY #PRIMARY CARE PHYSICIANEMERGENCY CONTACTEMERGENCY CONTACT PHONE #RELATIONSHIPEMPLOYEREMPLOYER PHONE #PHARMACY NAME & PHONE #Section BreakSome description about this sectionPRIMARY INSURANCE COMPANY NAMEEFFECTIVE DATEID#GROUP NUMBER.SUBSCRIBER NAME (NAME OF PERSON THAT HOLDS THE INSURANCE)SUBSCRIBER BIRTH DATESUBSCRIBER EMPLOYERPATIENT RELATIONSHIPSection BreakSome description about this sectionSECONDARY INSURANCE NAMEEFFECTIVE DATEID#GROUP NUMBER.SUBSCRIBER NAME (NAME OF PERSON THAT HOLDS THE INSURANCE)SUBSCRIBER BIRTHDATESUBSCRIBER EMPLOYERPATIENT RELATIONSHIPSection BreakSome description about this sectionPERSON RESPONSIBLE FOR PAYMENT( IF PATIENT UNDER THE AGE OF 18)DATE OF BIR THSEXSTREET ADDRESS (APT#)CITY, STATE AND ZIPCODEPHONE NUMBERCURRENT MEDICATIONS:LIST ANY POSSIBLE DRUG ALLERGIES:Signature On File Agreements ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR OFFICE BOOKKEEPER. INSURANCE AUTHORIZATION AND ASSIGNMENTNAME OF POLICY HOLDERHIC NUMBERI authorize any hold of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable to related services. I permit a copу of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information.)Signature Sign Here DateSubmit Form Patient Privacy Consent PATIENT PRIVACY CONSENT FormPATIENT NAME: I GIVE PERMISSION TO DR JALAJ AND DR DAS TO SPEAK WITH THE FOLLOWING RELATIVES OR INDIVIDUALS INDICATED BELOW REGARDING MY HEALTH CARE. NAMES/RELATIONSHIP NAMES: RELATIONSHIP I GIVE PERMISSION FOR THE DOCTORS OR STAFF TO LEAVE MESSAGES ON MY ANSWERING MACHINE IF I AM NOT AVAILABLE. DOCTOR OR STAFF MAY NOT LEAVE INFORMATION ON MY ANSWERING MACHINE.PLEASE NOTE OUR OFFICE ONLY SENDS MEDICAL RECORDS TO OTHER PHYSCIANS YOU ARE SEEING, OR TO YOUR INSURANCE COMPANY. WHEN YOU SIGN UP WITH YOUR INSURANCE COMPANY, YOU HAVE ALREADY GIVEN THEM AUTHORIZATION TO ACCESS YOUR MEDICAL FILE. THE ONLY OTHER TIME WE WILL DISCLOSE OF YOUR MEDICAL INFORMATION IS WITH A LEGAL SUBPEONA, OR WITH YOUR WRITTEN CONFIRMATION BY A THIRD PARTY. (e.g.: Life Insurance Requests, etc.)ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE This is to certify that I have been presented with a copy of Dr. Jalaj and Dr. Das's NOTICE OF PRIVACY POLICIES, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice.SIGNATURE OF PATIENT: Sign Here DATE SIGNED:If not signed by the patient, please indicate relationship to patient (eg spouse; parent; healthcare proxy; or guardian.)RELATIONSHIP:WITNESSED BY:INTERNAL USE ONLY: WITNESSED BY: If patient or patient's representative refuses to sign acknowledgement of receipt of notice, please document and date and time the notice was presented to the patient and sign below.Please explain any Yes answers in space provideрConstitutional SymptomsFever Yes NoChills Yes NoIntegumentary Skin rash Yes NoBoils Yes NoSubmit Form Allergy Questionnaire - Part 2 Allergy Questionnaire - Part 2What symptoms are you experiencing? (From #1 on intake form)How often do you experience these symptoms?Do you have any of these symptoms? Cough Wheezing Shortness of breath Chest tightness Sneezing Runny Nose Nasal Congestion Itchy Nose Itchy / Watery Eyes Postnasal Drip Nasal Polyps Poor Sense of Smell Ear Infections Sinus Infections Blocked Ears Eczema Hives / Swelling Headaches Snoring Fatigue Phlegm/sputum OtherPhlegim/sputum ColorOtherWhich of the following seems to bother you or trigger/cause the above symptoms? Plaintext Grass Nervousness House Dust Perfumes Other Animals Leaves Latex (rubber) Foods. Other. Cats Hay Cold Air Smoke Insecticides Alcoholic beverages Insect bites/stings. Cosmetics Dogs Mold & Mildew Humidity Pollution Odors Drafts Aerosol sprays Horses Basements Weather changes ExerciseInsect bites/stings. Describe reaction:List foods and reactions:Other. List sources and reaction:When are your symptoms worst? Year round January February March April May June July August September October November DecemberAre symptoms better away from home? Yes NoIf yes, when?Have you ever had an allergy skin test or blood test? Yes No If yes, results:Have you ever had allergy injections? Yes NoIf yes, when?Have you received cortisone (prednisone, methylprednisolone, etc.) drugs? Yes NoIf yes, when?How much?Are you on allergy medications? Yes NoWhat meds?How much?For how long?What is your occupation? (current or former)THIS SECTION FOR PROVIDER AND OFFICE USE ONLYIs patient... Suffering from uncontrolled asthma History of anaphylaxisIf yes to above, refer out toispecialist On beta blocker? regnant? Heavily tattooed? Significantly immunocompromised or have malignancy or severe chronic illness?If yes to above, select blood test Yes NoWheezing or having difficulty breathing? Yes NoIf yes to above; treat symptoms and schedule for another dayHaving symptoms consistent with food allergies? Yes NoIf yes to.above, consider skin panel and food panelIndicationsSkin TestBlood TestInhalant Panels:IndicationsSkin TestBlood TestFood Panels:Schedule skin test for (Date):Patient NameBirthdateReviewed byDateSubmit Form
