Patient Form

(Click Below to Download)

New Patient Packet
Assignment of Benefits

Release Records to Capital Allergy
Sacramento / Roseville / Folsom

New Patient Fax/eMail Cover Sheet
Sacramento / Roseville / Folsom

Permission to be Involved in Patient Care

Capital Allergy to Release Record

Release of Antigen Consent Form

Antigen Cost Consent Form

Antigen Cost Form

Permission to be Involved in Patient Care

Testing Sheet Consent

Testing Sheet Consent Renewal

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Dear New Patient,

The physicians and staff of Capital Allergy & Respiratory Disease Center thank you for your confidence in our practice to meet your health needs. As board certified specialists in adult and pediatric allergy, asthma and immunology, we will work hard to provide only the highest level of care. To provide you with the very best care your initial visit could last one to three hours. To view instructions for patients prior to allergy skin testing click here.

Our usual new patient fee ranges from $125.00 to $255.00. Charges for allergy testing, lung function tests or other laboratory tests are additional. Laboratory tests and x-rays are billed by the laboratory or hospital and will vary greatly depending on the individual needs of the patient.

We will submit insurance claims for you. Please complete the registration forms entirely and bring your primary and/or secondary insurance cards with you. Payment of your bill after insurance is due upon receipt of our statement.

Come prepared to pay your copay, deductible and coinsurance as these are due at the time of your visit and will be collected upon your arrival. We accept cash, check, Visa, Mastercard and debit cards.

Once again, we want to thank you for giving us the opportunity to meet your medical needs and if you should have any further questions, please feel free to contact our office. We are looking forward to seeing you!

DUE TO THE NATURE OF OUR PRACTICE WE ASK THAT YOU DO NOT WEAR ANY PERFUME, COLOGNE, SCENTED LOTIONS OR SPRAYS.

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