Patient Intake Forms

With the new office environment and recommendations, we have created a secure form to obtain your personal health information. Please take time to fill this form out prior to your office visit. Thank you, Dr Allan Panzer

Please correct the errors described below.

Patient Information

Where correspondence can be sent if necessary.
Able to receive text messages.
If same as cell phone, type in cell number

Medical and Vision Insurance information

Listed on medical card
Located on the of the card for benefits
Supplementary Insurance
Maybe SSN, if so, use the last 4 of SSN
    Please upload a file

    For insurance purposes only.

    Review of Medical Systems

    List problems with vision.
    If first exam, type First

    Check all that apply, a review of these conditions will be done at your visit.

    for Self or Family

    List of Medications currently taking.

    Add more medications

    Thank you for completing the form, look forward to taking care of your eye care needs. Dr Allan Panzer.

    Your information will be encrypted.

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