Panzer Dermatology Associates

Panzer Dermatology and Cosmetic Surgery
Apex Medical Center
537 Stanton-Christiana Road
Suite 107 & 207
Newark, DE 19713

Telephone: (302) 633-7550
Fax: (302) 633-7556

Click here for our office hours.

In order to make it easier for new patients to register and schedule an appointment, we have provided the form below. This form will send a Consultation Request to our office staff, who will then call to schedule your appointment.

Patient Name:
*

Guarantor Name, if Patient is a minor

Street Address:

Apartment:

City:

State:

Zip Code:

Home Phone Number:

Cell Phone Number:

Birthdate:

Marital Status:

Gender:

SSN:

Email:
*

Insurance Information

Insurance Company Name:

Insurance Address:

Insurance Phone Number:

Insurance Plan Type

Policy/Member/ID Number:

Group Name:

Group/Account Number:

Specialist Copay

Subscriber Name

Subscriber Date of Birth

Employer Information

Employment Status:

Company Name:

Company Address

City:

State:

Zip Code:

Office Phone Number:

Ext Number:

Occupation:

Referring Doctor

Family Doctor

Reason for Appointment and preferred date(s) or day(s) of the week and time:

*Required fields