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.
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
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.