Patient Intake Form

Today's Date:
MM slash DD slash YYYY
Date of Birth:*
MM slash DD slash YYYY
Name*
First Last
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Cell Phone:
Email Address:*
Enter Email Confirm Email
Credit Card Information:
- Visa
- Mastercard
- Amex
- Discover
Name on Credit Card:
First Last
Credit Card Number:
Credit Card Expiration Date:
MM slash DD slash YYYY
Credit Card Security Code:
Credit Card Billing Zip Code:
Who referred you to me?
Other doctor(s) who treat you and for what condition? Please list:
Patient Responsibility Statement:*
- I do accept the following statement:
- I do not accept the following statement:
I understand that I am responsible for my entire fee at the time of my visit. I authorize Dr. Steven A. Sobelman, P.A. to provide treatment plans to my insurance carrier, if needed, and with my approval. Additionally, I will be responsible for full payment of missed appointments when 24 hour notice is not given for cancellation of an appointment.