Patient Forms

Download patient forms

If you are a new patient, or if any of your personal information has changed since your last visit, please complete the forms below. You can fill out your patient forms in the office, or print and complete them before your visit.

For assistance with accessing these forms or to request these documents in an alternative format, please contact the appropriate scheduling department:

For the Bloomington clinic, call (812) 855-8436, option 1

For the Indianapolis clinic, call (317) 278-1470, option 1.

Patient forms (English)

Patient Information Form

Fill out your personal information, including home address, contact information, and insurance.

Email and Text Authorization Form

Let us know whether you would like to receive appointment reminders via text message or email.

Medical History Form

Tell us about your current medications, allergies, medical history, and family history.

Notice of Privacy Practices

Click here to review the current IU School of Optometry's Notice of Privacy Practices

Patient Bill of Rights and Responsibilities

The current IU School of Optometry's Patient Bill of Rights and Responsibilities can be found by clicking here

Patient Concern Form

Patients with concerns about the care they received in an IU School of Optometry clinic can fill out this form to register their concerns

Formularios para pacientes (Español)

Formulario de Información del Paciente

Complete su información personal, incluida la dirección de su casa, la información de contacto y el seguro

Formulario de Autorización por Correo Electrónico y Mensaje de Texto

Háganos saber si desea recibir recordatorios de citas por mensaje de texto o correo

Formulario de Paciente de Historial Médico

Cuéntenos sobre sus medicamentos actuales, alergias, historial médico y antecedentes familiares

Patient forms for patients 12 years and younger

Pediatric Medical History Form

Detail your child’s medical and developmental history, as well as previous medical tests, evaluations, and vision care.

Consent to Treat Minor Patient

Authorize the IU School of Optometry to treat your child, and list the adults who may accompany your child at their appointment.

Patient referral form

Health care providers can refer patients to the IU School of Optometry using the Patient Referral Form. Referrals can be made for:

Consultations
Second opinions
Transfer of care
Special testing
Treatment or therapy

Fax the completed form (fax numbers are included in the form) to the appropriate service.

Download the patient referral form