Allergies Information Form Allergies Information Form Allergies Information FormWhen you submit this form, we will send an email to the physician's email address for completing the Physician's Order form.Student’s Name* First Last DOB (MM/DD/YYYY)*Parent's Name*Parent’s Telephone Number (H)*Telephone Number (W)*Parent Email* What is your child allergic to?*When and how many times did your child exhibit this allergic reaction? (Gives dates)*Description of past allergic reaction*What steps were taken at that time?*Give name, address and telephone number of physician who has treated or is aware of this allergic reaction.*Allergy Special Care Plan Drop files here or Physician’s Name*Physician's Address*Physician's Email Address* Physician's Telephone Number*Parent’s Signature*Date* Date Format: MM slash DD slash YYYY When you submit this form, we will send an email to the above-mentioned physician's email address for completing the Physician's Order form.
