Welcome to Fit Feet Podiatry, and the practice of Dr. Leon Stepensky
3111 Brighton 2nd Street
Brooklyn, NY
718-332-8633
99 Moore St
Brooklyn, NY
718-387-1884
235 Wyckoff Ave
Brooklyn, NY
718-418-4700

Book an Appointment

BOOK AN APPOINTMENT WITH DR. LEON STEPENSKY ONLINE AT ZOCDOC.COM

 


First Name:     Last Name:
Date of Birth:      Social Security Number (SSN):
Address:     City:     State:     Zip Code:
Sex:     Marital Status:     Are You Employed?
Insurance:     Who is responsible for this account?
Subscriber's Name:
Date of Birth:      Social Security Number (SSN):
Preferred Language:
Race:
Phone #:     Cell Phone #:     E-mail:
In case of emergency, contact:     Phone #:

Primary Care Physician:
Phone #:     Last Date Seen:
Address:     City:     State:     Zip Code:
Pharmacy Name:
Phone #:     Whom may we thank for referring you?

Current Medications
Status:
Name:     Dose:
Name:     Dose:
Name:     Dose:

Allergies
Status:
Name:     Reaction:
Name:     Reaction:
Name:     Reaction:

Medical History
Diabetes:     Are you on insulin?     High cholesterol:
Other:

Smoking Status:

PLEASE READ AND SIGN:
The information on my intake form(s) is correct and to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above.
(Assignment of Benefits): I authorize payment of medical benefits to the practice named above.
(Release of Information): I authorize the release of any medical information necessary to process this claim.
(HIPAA Privacy): I acknowledge that I received my HIPAA Privacy Practices Notice.
(Medication History): I authorize the Doctor's office to retrieve my medication history.