BSACI Clinic Registration/Update Form

Name of person completing form
Contact telephone number
Contact e-mail address
Clinic Name
Clinic Name (short display if different to name above )
Hospital
Address Line 1
Address Line 2
Town
Postcode
Appointments tel:
Direct tel:
Fax:
E-mail:
Do you agree to have your clinic details displayed on the BSACI website? /  Yes  No

Children’s Services

Are children seen at the clinic? Yes  No

Are they seen by:-

  • Paediatrician (Allergist) Yes  No
  • Paediatrician (General) Yes  No
  • Adult physician (Allergist)  Yes  No
  • Adult physician (General) Yes  No

(*If yes, please specify primary speciality):

 Immunology

 Respiratory Physician

 Dermatology

 ENT Surgeon

 Other (please specify)

Services offered at the clinic

Are the following services offered at your clinic:-

Allergy affecting chest

Not available Adults Only Children only Adults &Children

Allergy affecting nose

Not available Adults Only Children only  Adults &Children

Allergy affecting skin -urticaria and angioedema

Not available Adults Only Children only  Adults &Children

Allergy affecting skin – Eczema

Not available Adults Only Children only  Adults &Children

General anaesthetic allergy

Not available Adults Only Children only  Adults &Children

Anaphylaxis

Not available Adults Only Children only  Adults &Children

Drug allergy without challenge

Not available Adults Only Children only  Adults &Children

Drug allergy with challenge

Not available Adults Only Children only  Adults &Children

Food allergy

Not available Adults Only Children only  Adults &Children

Venom allergy

Not available Adults Only Children only  Adults &Children

Latex allergy

Not available Adults Only Children only  Adults &Children

Occupational allergy

Not available Adults Only Children only  Adults &Children

Desensitisation/immunotherapy

Not available Adults Only Children only  Adults &Children

Is Immunotherapy available for?

Pollen Yes  No 

Non pollen inhalants (e.g. dust mite/cat) Yes  No 

VenomYes  No 

What routes of immunotherapy are available?

Sublingual only Subcutaneous only Both

Regular challenge sessions

Not available Adults Only Children only  Adults &Children

Regular day case sessions

Not available Adults Only Children only  Adults &Children

Please list all staff members at the allergy clinic

Name / Position / Specialism

Additional clinic information

Please send completed form by post to above address or by e-mail to