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

Patient Information

First Name

Last Name

Date of Birth

Gender

Male Female

Home Address

Where correspondence can be sent if necessary.

City

State

Zip Code

Email address

Cell Phone

Able to receive text messages.

Home Phone

If same as cell phone, type in cell number

Preferred method of communication Check all that apply

Email

Cell Phone

Home Phone

Permission to send texts

Yes

No

Occupation

Employer

Medical and Vision Insurance information

Medical Insurance Carrier

Medical ID Number

Listed on medical card

Primary insured or Policy Holder

Primary insured Date of Birth

Medical Insurance Group Number

Provider Line Phone Number

Located on the of the card for benefits

Secondary Medical Insurance

Supplementary Insurance

Secondary Coverage ID Number

Vision Plan

Vision Plan ID Number

Maybe SSN, if so, use the last 4 of SSN

Attached a scanned copy of medical and vision cards.

Add file

Please upload a file

For insurance purposes only.

Review of Medical Systems

How is your general health?

Primary Care Phycisian or Specilist managing conditions

What is the main purpose of your visit?

List problems with vision.

Date of last eye exam?

If first exam, type First

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

Other medical or eye conditions not listed above

for Self or Family

Medical Surgical History

List of Medications currently taking.

Medication

Strength

How often taken?

Add more medications

Allergies to Medicine or Environmental Allergies

Eye conditions discussed or diagnosed at previous eye exams.

Glaucoma

Cataracts

Corneal Problems

Dry Eyes

Retinal Problems

Macular Disorders

Eye Muscle Disorders

None

Contact Lens wearer?

Yes

No

Interested in trying.

If yes, what type of lenses are worn?

Soft Contacts (daily disposable)

Soft Contacts (2 week disposable)

Soft Contacts (monthly disposable)

Rigid Gas Permeable

Scleral Lens

Hybrid Lens

N/A

Contact Lens Brand

Solution used for cleaning

Had any eye surgery?

Yes

No

If yes, please list eye surgeries

Anything else that your would like to let us know?

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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