New Patient Office Visit

The following documents will help expedite the registration process for your appointment. We ask that you please complete the following forms. The completed forms may be returned via mail, faxed to: (859) 277-4405, emailed to: office@justinsaunders.com, or brought with you to your appointment. Please call our office if you have any questions regarding these documents. Thank you for your assistance.

Online Forms

Patient Health History Online Form
Financial Policy Online Form
Authorization For Release of Information Online Form
Advanced Beneficiary Notice Online Form
Email Consent Form
Surgery Policy Form

Printable Forms

Patient Health History Form (pdf) (Size: 169kb)
Patient Eligibility Waiver and Financial Responsibility Form (pdf) (Size: 31kb)
Authorization for Release of Information Form (pdf) (Size: 28kb)
Advanced Beneficiary Notice Form (pdf) (Size: 832kb)
Email Consent Form (pdf) (Size: 568kb)
Surgery Policy Form
Informed Consent for Stopping or Continuing Blood Thinners (Anticoagulants)
Blepharoplasty Consent Form
Informed Consent for Conjunctivo-Dacryocystorhinostomy (C-DCR) "Tear Drain Bypass Surgery"
Consent form for Incision and Drainage of Chalazion
Informed Consent for Dacryocystorhinostomy
Informed Consent for Ectropion ("Lower Lid Repair")
Informed Consent for Entropion Surgery ("Lower Eyelid Repair")
Consent Form for Excision of Eyelid Lesion(s)
Informed Consent for Ptosis Surgery (Droopy eyelid surgery)
Informed Consent for Skin Cancer Surgery Repair (Repair of defect after skin cancer removal)
Informed Consent for Temporal Artery Biopsy ("Biopsy of an artery near the hairline")
Consent form for Exposure Keratopathy

Please remember to bring your completed forms, along with the following pieces of information, to your scheduled appointment:

  • Insurance card
  • Photo ID
  • Referrals (If required by your insurance)
  • Co-payments (If required by your insurance)