7744 66th St N Pinellas Park FL, 33781

Booking Online

Patient Info

Booking Your Appointment

We’re pleased to offer convenient online booking for your visit with Dr. Michele Selsor. Whether you’re a returning patient or scheduling your first consultation, our goal is to make the process easy and efficient.

How to Book:

  • Returning Patients:
    Click the Book Now button to schedule your appointment online.
  • New Patients:
    You may book online, but please complete the new patient intake form before your first visit.
  • Downloadable Forms for New Patients:
    If you'd prefer to fill out the form by hand download and complete the new patient forms found at the bottom of this page. Bring them to your appointment. Otherwise you can fill out this electronic form prior to your visit.
  • If you prefer, you may also call our office directly to schedule your visit.

Patient Information

Person Responsible for Payments (if different from patient)

Emergency Contact

Communication: Circle all that apply

Insurance

I authorize the release of any medical information necessary to process an insurance claim.
-and
I authorize payment of benefits, either to myself, or Dr. Michele L Selsor as agreed upon at the time of services rendered and/or according to contract with my insurance company. I agree that I am responsible for and will pay any deductibles or copayments as contracted with my insurance company.
-or
If you are NOT using insurance:
I am solely responsible for and agree to pay the incurred charges received by the doctor.

PLEASE SIGN BELOW EVEN IF YOU ARE NOT USING INSURANCE

No Show & Late Cancellation Policy

If you need to reschedule your appointment, please give the office a notice at least the day before your appointment. This allows the office to have time to schedule other patients who are wanting to get put on the schedule.

Please read the following below in regards to our no show policy.

  • Any patient that fails to show up to their appointment will be contacted. The office will contact the patient in regards to their appointment. If the patient reschedules, a no show fee will not be charged. Should the patient fail to reschedule and/or does not show up to the rescheduled appointment, a no show fee of $45 will be charged.
  • Patients that fail to reschedule their appointment that they cancelled at the last minute will be charged a no show fee of $45. A patient that continuously reschedules their appointment after multiple last minute cancellations will be charged a fee after the 3rd time..
  • The fee is charged to the patient directly and not the insurance company. The no show fee is due at the patient's next appointment. Failure to pay the fee will prevent Dr. Selsor from seeing the patient until it is paid.
  • As a courtesy, the office will send reminder calls the week before the patient's scheduled appointment. Please note the policy is still in effect even if you do not receive the call. Please make sure you provide the correct contact information.
We understand that emergencies out of the patient's control can happen that prevent the patient from keeping their appointment. You may call the office at 727-321-9488 regarding your emergency and can have the fee waived.

By signing below, you agree to the above terms and conditions

Primary Doctor

Check all that apply:

Smoking Status

I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my lower extremities from the knee down.

Florida Law (Section 817.5655, Florida Statutes) prohibits the sale or transfer of a person’s biological specimen from which DNA can be extracted to a third party without the express consent of such person. During the course of your care at Dr. Michele L Slesor, D.P.M, it may be medically necessary to obtain blood, urine, stool, tissue, or other types of biological specimen for analysis. This analysis will not involve the examination of your DNA to identify the presence and composition of genes in your body. After the analysis has been performed and the sample is no longer needed, it will be stored as medical waste and then transferred to a third party for disposal in accordance with all local, state, and federal requirements.

It may also be the case that a biological specimen (such as blood, urine, hair, bodily fluids, etc.) from you may be deposited on medical instruments, bedding, clothing or other objects, These objects may then be transferred to a third party for cleaning or disposal.

By Signing this document, you affirmatively state that it is your intentional decision to sensent to the transfer of any and all biological specimens collected by or deposited with Michele L. Selsor, D.P.M to a third party as set forth above. This consent does not authorize the sale or transfer of a biological specimen for the purpose of DNA analysis.

Acknowledgement of Receipt of Notice of Privacy Practices (Pg 7-12)

Parent or Authorized Representative (if applicable)

Download PDF

Patient Information

Person Responsible for Payments (if different from patient)

Emergency Contact

Communication: Circle all that apply

Insurance

I authorize the release of any medical information necessary to process an insurance claim.
-and
I authorize payment of benefits, either to myself, or Dr. Michele L Selsor as agreed upon at the time of services rendered and/or according to contract with my insurance company. I agree that I am responsible for and will pay any deductibles or copayments as contracted with my insurance company.
-or
If you are NOT using insurance:
I am solely responsible for and agree to pay the incurred charges received by the doctor.

Primary Doctor

Check all that apply:

Smoking Status

I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my lower extremities from the knee down.

Florida Law (Section 817.5655, Florida Statutes) prohibits the sale or transfer of a person’s biological specimen from which DNA can be extracted to a third party without the express consent of such person. During the course of your care at Dr. Michele L Slesor, D.P.M, it may be medically necessary to obtain blood, urine, stool, tissue, or other types of biological specimen for analysis. This analysis will not involve the examination of your DNA to identify the presence and composition of genes in your body. After the analysis has been performed and the sample is no longer needed, it will be stored as medical waste and then transferred to a third party for disposal in accordance with all local, state, and federal requirements.

It may also be the case that a biological specimen (such as blood, urine, hair, bodily fluids, etc.) from you may be deposited on medical instruments, bedding, clothing or other objects, These objects may then be transferred to a third party for cleaning or disposal.

By Signing this document, you affirmatively state that it is your intentional decision to sensent to the transfer of any and all biological specimens collected by or deposited with Michele L. Selsor, D.P.M to a third party as set forth above. This consent does not authorize the sale or transfer of a biological specimen for the purpose of DNA analysis.

Cancellation & No‑Show Policy

We understand that sometimes schedule changes or emergencies arise. To provide the best access for all patients and maximize provider time.

we have adopted the following policy:

  • Please cancel or reschedule at least 24 hours in advance.
  • Late cancellations (less than 24 hours’ notice) will incur a $40 fee.
  • No-shows (missed appointments without notice) will incur a $100 fee.
  • These fees are your responsibility and are not billable to insurance.
  • In cases of emergency or extenuating circumstances, we may waive or reduce fees at provider discretion (documentation may be required).
  • Repeated violations may result in requiring a deposit, limiting scheduling options, or dismissal from the practice (with appropriate notice).
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