Office Forms
If you're new to our office, or we just haven't seen you in some time, we would appreciate your current information.
New patients: please complete the appropriate Medical History Form, Patient Demographics/Insurance Authorization, Patient Communication Consent Form, and Kendall L. Krug, OD PA Practice Policies/HIPAA Privacy Policies. If you have a previous OD, please complete the Authorization for Release as well.
For Referring Doctors: please select the Low Vision Patient Consultation Form, complete sections 1 & 2, sign and fax to us at 785-625-7490.
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Pediatric Medical History Questionnaire (for ages 12 years and younger)
Adult Medical History Questionnaire (for ages 13 years and older)
Patient Demographics / Insurance Authorization
Patient Communication Consent Form
Kendall L. Krug, OD PA Practice Policies/HIPAA Privacy Polices
Authorization for Release of Protected Health Information (records release)
Low Vision Patient Questionnaire and Information
Low Vision Patient Consultation Form (for referring physicians only)
Please complete the form(s) in their entirety, and mail or fax to us AT LEAST ONE WEEK PRIOR TO YOUR SCHEDULED APPOINTMENT.
Mailing Address:
Kendall L. Krug, OD PA
2203 Canterbury Dr.
Hays, KS 67601
Fax Number: (be sure to fax BOTH sides of completed form, if applicable) 785-625-7490