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 emailing the forms before your visit, email the Dupont location at Dupont@Korrect.com; and the Dixie location to Dixie@Korrect.com. 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.
Click for Printable PDF

NOTICE OF PRIVACY PRACTICES – HIPPA INFORMATION
Information regarding patient privacy, requiring patient review and signature.
Click for Printable PDF

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.
Click for Printable PDF

PATIENT FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS
All patients must fill out this form.
Click for Printable PDF

OPTOMAP® RETINAL EXAM ACCEPTANCE FORM
Use this form to accept an Optomap eye examination
Click for Printable PDF

CONTACT LENS EVALUATION AGREEMENT
If you want an evaluation for contact lenses, please complete this form.
Click for Printable PDF


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