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.