Please print this form, complete it, and bring it to your visit.


CLIFFORD W. BASSETT, M.D.
Allergy & Asthma Care of New York
425 Madison Avenue
11th Floor
NY, NY 10022
212-759-8644		 381 Park Avenue
South Suite 1020
NY, NY 10016
212-260-6078
 150 Broadway
Suite 1601
NY, NY 10038
212-964-1295		 560 Broadway Ste 406
NY, NY 10012
212-964-1295		 142 Joralemon St.
Suite 3A
Bklyn Heights, NY 11201
718-246-3700		 201 East 65th St.
NY, NY 10065
212-260-6078
Pharmacy Info Email Electronic Prescription Program



Patient's Name:        _________________________________________
 		Date of Birth:______________     Age: _______



Pharmacy Name:      __________________________________________________________________



Pharmacy Address: __________________________________________________________________

                                 __________________________________________________________________

                                 __________________________________________________________________



Pharmacy Phone:     __________________________________________________________________