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Patient Forms

For your convenience, before you visit our locations for your appointment, you may fill out and send the appropriate registration forms via email or fax – or you can complete the forms, print them out, and bring them with you.

If you are faxing the forms before your visit, fax the Dupont visit form to (502) 736-9762; and the Dixie visit form to (502) 447-3083.

Assistance on completion of any of these forms is available by calling (502) 895-2020.

Patient Registration Form

If you are seeing one of our doctors at the time of your visit – please complete this form.

Notice of Privacy Practices – HIPPA Information

Information regarding patient privacy, requiring patient review and signature.

Advance Beneficiary Notice

Fill out only if a Medicare patient. This completed form can only be faxed or printed, and brought in at the time of your visit.

Optomap® Retinal Exam Acceptance Form

Use this form to accept an Optomap eye examination

These forms are also available in our offices and can be filled out at the time of your appointment.