Anna Shender M.D., D.O.
66 Glenbrook Rd Ste 400, Stamford CT 06902
Phone: 203-961-8241

 New Patient Intake Forms

We want to make your first visit with us a success and as productive as possible. Please arrive a few minutes early so you have time to fill out our health status forms. This will help the physician to learn about any areas requiring care. Filling out these forms will help your physician make the most of your time together. If you are insured, please bring your insurance card or a clear copy of one. Please do not forget to bring to your first visit the bottles of all medications you are taking. Please arrange for your medical records to be transferred (use Medical Records Transfer form below).

• Patient Demographics/Medical History
• Consent/Privacy Notice

 Medical Records Transfer

If you are interested in obtaining a copy of your health Information, please download, print and complete the Authorizaton for Release of Protected Health Information form linked below.

• Records Release Form

Upon completion, you may fax, mail, or personally deliver your Authorization.

NOTE: An institution can charge up to 65 cents per page, including any research, clerical, and handling fees or related costs, and first class postage, if applicable. The institution can also charge the amount necessary to cover the costs of material for providing a copy of an x-ray or for furnishing an original retained slide, an original tissue block, or a new section cut from a retained pathology tissue block. (CGS § 19a-490b(a)).