Dr. Black's Eye Associates of Southern Indiana
302 West 14th Street, Suite 100A
Jeffersonville, IN 47130
Phone: (812) 284-0660
Monday—Friday | 8 a.m.– 5 p.m.
Dr. Black's Eye Associates of Southern Indiana
302 West 14th Street, Suite 100B
Jeffersonville, IN 47130
Phone: (812) 284-1700
Monday—Friday | 8 a.m.– 5 p.m.
Patient Forms
We want your visit to be as comfortable and relaxing as possible. Sometimes it’s easier to remember everything when you can fill out forms in the comfort of your own home. Simply download and print these forms, provide the requested information, and bring them with you to your first appointment.
- Privacy Authorization (Notice of Privacy Practices)
- SPANISH – Privacy Authorization (Notice of Privacy Practices)
- New patient packet (adult)
- SPANISH – New patient packet (adult)
- Medical history form (adult)
- SPANISH – Medical history form (adult)
- New patient packet (child)
- SPANISH – New patient packet (child)
- Medical history form (child)
- SPANISH – Medical history form (child)
- Minor Consent Form
- SPANISH – Minor Consent Form
- Refraction Authorization Agreement
- SPANISH – Refraction Authorization Agreement
- HIPAA Compliance Patient Consent Form
- SPANISH – HIPAA Compliance Patient Consent Form
If you don’t have a way to download them, or if you prefer to fill out your forms when you arrive at our office, that’s okay!
Please be sure to read our Good Faith Estimate disclaimer for non-emergency healthcare services before you schedule your appointment with Dr. Black’s Eye Associates. Thank you!
Either way, we are looking forward to your visit!
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