FORMS for Patients

New Patients:

Set up an Appointment: (606) 219-4184 

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Forms:

FYI- You can get results faster if you download and fill in these forms before your appointment.  Please drop them by our office or FAX to: 606-678-8368 

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For All Patients:

Insurance as well as Self-Pay Payment Agreement​

 

Authorizations for Release of Information (so KBC can get your Prior Images & Reports):​

• for Prior Breast Images

• for Prior Breast Ultrasound/Sonogram Images (if you were under 30)

• for Prior BODY (arm, head, chest, etc) Ultrasound, CT or X-Ray Images

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Optional Patient Forms:

If you want to grant access of your Medical Records/Reports to your Approved Friends or Family Members, please fill in: HIPPA Release Form

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If You are Pregnant, please fill in: Pregnancy Consent Form

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