oit phone consult request form

Thank you for your interest in our oral immunotherapy (OIT) program for food allergies.  A free phone consultation with Dr. Jacobs is available to help determine if OIT might be right for you and your family.  In order to make the most of your phone call, please fill-out and submit the following form.  After you submit, Dr. Jacobs will email you to set-up a mutually convenient time for a phone call.  If you have any questions, please do not hesitate to email us at centerforallergy@gmail.com or call us at 816.531.0930.

Contact Name *
Contact Name
Phone *
Phone
Relationship to patient *
What are the symptoms when the patient eats the food(s) in question? *
Check all that apply
Has the patient had positive allergy testing to the food(s)? If so, having the records out in front of you at the time of the phone call would be great but it is not necessary. *
Please check all meds that the patient has received for treatment of an allergic reaction
Is the patient's quality of life impacted by food allergy? *
Is the family's quality of life impacted by food allergy? *