New Patient Forms

Filling out forms is never fun! Save yourself some time, energy, and hassle on the day of your first patient appointment by filling them out in advance and bringing them with you.
If you have any questions, call us and we will assist you.

Our Cary office can be reached at 919-443-2557.

**Please note, at this time, patient forms cannot be submitted through this website. Patient’s please PRINT these forms and bring them with you to your appointment**

New Patient Forms

New patient appointments usually take 1 hour, depending on your specific condition. For your convenience, we have attached a Patient Registration Form, a Medical History Form (be sure to list all prescription medicines, vitamins/minerals, and herbal preparations you are taking), and a Patient Privacy Form (HIPPA). You do not have to necessarily print the HIPPA form, but you must review the document so you are aware of your Privacy Rights. By signing the Receipt of the Privacy Rights Form, you are accepting and acknowledging that you were informed of your rights to privacy according to HIPPA.

To ensure a timely appointment, please be sure to complete and bring these forms with you to your visit. By filling these out ahead of time, you will save significant time at the beginning of your visit. You may also fax the forms to our office prior to your visit: 919-869-1869.
If you have any questions when filling out these forms, our staff will be happy to assist you. Once you arrive to your appointment, there may be some other forms to fill out and sign as well.

What to Bring to Your Appointment

  1. Completed forms
  2. Insurance cards
  3. Driver’s license

Please note that payments are due at the time services are rendered.
We participate with most major insurance plans. For these plans, co-payments, deductibles, and co-insurance will be collected at the time of service. Payment in full is requested at the time of the visit for patients on insurance plans with which we do not participate, or patients who are self-pay. We accept cash, checks, Discover, MasterCard, and Visa. We look forward to meeting and assisting you with your Oculofacial needs!

Physician Referral Forms

For doctors’ offices requesting a consultation, please download and complete the Referral Form and fax it back to us at 919-869-1869.

For the convenience of their patients, Drs. Renzo Zaldívar, Peter Kreymerman, and Cassandra White are accepting new patients in the Cary and Greensboro locations.