Dr. Richard Zobel

  • Patient Information

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  • Vision/Medical Insurance Information

    It is the patient's responsibility to inform the front desk of any changes to insurance.
  • Medical History

    Check all conditions that apply.
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  • Patient Signature

    I hereby grant permission for Dr. Richard Zobel to exchange information with my insurance company concerning my history/results of my examination/diagnosis/treatment. I hereby assign all medical benefits to which I am entitled. I understand that I am financially responsible for all charges whether paid by said insurance or not. It will be the patient's responsibility to provide our office with any required referrals. I authorize this office to release any information needed to determine the benefits for related service. Patients without insurance are responsible for all charges at time of visit.
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