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.
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 these forms, provide the requested information, and bring them with you to your first appointment.
- Privacy authorization
- New patient packet (adult)
- Medical history form (adult)
- New patient packet (child)
- Medical history form (child)
- Vision Supplement Follow-up Request form
- Refraction Authorization Agreement
- 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!
Either way, we are looking forward to your visit!Back to Top