Contact | Carol Dimitriades

Child's Name & age (if applicable)

Phone No.

Current Allergies/Health Issue

Please Include SKIN TEST results and RAST numbers from allergy testing within the last year (include Total IgE level for RAST test

Have you (or child) been prescribed and EpiPen?

Have you (or child) had an anaphylactic reaction? If yes, please explain (include dates)

Additional Details Related to Current Health Issues

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