Patient Form

(Click Below to Download)

New Patient Packet
Telemedicine Consent Form
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

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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***Updated 7/6/2020***

FROM CAPITAL ALLERGY & RESPIRATORY DISEASE CENTER
Due to current recommendations made by the US Government/CDC – The Following will go into effect until further notice.

Within the health care community as a whole, there has been an overall increase in the number of patients not seeking necessary medical treatment due to concerns about COVID-19.

If you have a medical problem, please contact your health care provider. It’s important not to delay seeking treatment when you need it.

We are currently open for in-office visits and will continue to offer telemedicine visits moving forward. We understand you might have concerns about coming in to see your health care provider. We want you to know about the steps we are taking to ensure your safety and help prevent the spread of infection:

o Mandatory Masking – All patients and visitors must be masked while in any of our care sites. Please wear a mask or face covering when you enter our facility.

o Limiting Individuals at Appointments – We will limit who is present at a patient visit. Only the patient will be allowed into the facility. If the patient is a minor, only one parent/guardian will be allowed to accompany the patient.

o Temperature Checks – All patients (and parent/guardian if patient is a minor) will have their temperatures checked at the door. Anyone with a temperature of 100 degrees or higher will be asked to reschedule their appointment or conduct the appointment via telemedicine.

o Employee Screening – We’ve instituted mandatory employee temperature screenings before each shift.

New Injection Hours – Effective 7/6/2020

Folsom Office
Monday 8:00-11:45 / 1-4:45
Tuesday Closed
Wednesday 8:00-11:45 / 1-4:45
Thursday 8:00-11:45 / 1-4:45
Friday 8:00-11:45 / 1-4:45

Roseville Office
Monday 9:00-11:45 / 1-4:45
Tuesday 8:00-11:45 / 1-4:45
Wednesday 8:00-11:45 / 1-4:45
Thursday 8:00-11:45 / 1-4:45
Friday 8:00-11:45 / 1-4:45

Sacramento
Monday 9:00-4:45
Tuesday 8:00-5:45
Wednesday 8:00-4:45
Thursday 9:00-4:45
Friday 8:00-4:45