Patient Registration

Before your first visit, please help us by completing the following interactive form at least 24 hours prior to your appointment. Established patients are asked to update their forms annually. Also, please review our privacy practices.

Personal Information

Gender:

Marital Status:

Ethnicity:

Race:

Contact Information

Preferred Method of Contact:

Minor Information

Student Status:

Spouse Information
Patient or Parent/Legal Guardian Employment Information

Employment Status:

Emergency Contact Information
Responsible Party Information

Responsible Party:

Referring Physician & Pharmacy Information
Referral Information
Medical/Vision Insurance Information

Do you have medical insurance to cover your examination or treatment?

Do you have vision insurance to cover your examination or treatment?

Does your insurance company require a formal authorization or referral from a primary care physician for our services?

Accident Information

Is your treatment for an injury or accident?

Were you injured at work?

Is this covered by Workers' Compensation?

Release of Information

I authorize the release of any medical information necessary to process insurance claims, and I authorize payment of medical benefits to Indiana Eye Clinic. I am financially responsible for all services provided by Indiana Eye Clinic to me or my dependents. If Indiana Eye Clinic is not a participating provider in my insurance plan, I understand that payment is required at the time of service. If my insurance requires a referral from my primary care physician, I will provide the referral at the time of service.

Financial Responsibility Statement

I acknowledge responsibility for payment of all medical fees regardless of insurance I may have to assist me in this responsibility. The only exception will be charges for services covered under a contractual agreement that has been entered into between my physician and an insurance company or other third party payor. If for any reason my account should become delinquent, I am liable to pay all collection and legal fees.

Release of Medical Information

On occasion a family member, friend, or caregiver may contact the Indiana Eye Clinic to inquire about your medical information. Please list authorized individuals to whom your information may be disclosed:

Medical History
Select Yes if you have any of the following conditions listed in the table below:
Yes No Medical Condition
High Blood Pressure
Diabetes
Cancer
Heart Disease
Breathing Problems
Kidney Disease
Circulation Problems
Ear/Nose/Throat
Stomach Problems
Neurological Disorders
Psychiatric Disorders
Skin Disorders
Allergic/Immune
Thyroid
Migraines/Headaches
Muscle/Skeletal
Other
Do you smoke?
Any tobacco use?
Do you drink alcohol?
Do you live alone?
Are you pregnant?
Family/Medical Doctor(s) History List your last two family/medical doctors:
Surgical/Hospitalization History List all surgeries or hospitalizations in the last 10 years, including prior eye surgeries, and the date of each one:
Medication History Please list all medications you are currently taking (including dosage)
Allergens Please list all medications you are allergic to:
Please check the following items you are allergic to:
Ocular History Have you been diagnosed with any of the following in the past?
Yes No Medical Condition Date/Comments
Cataracts
Retinal Disorder
Crossed Eyes
Corneal Disease
Glaucoma
Injury
Other Eye Disorders
Eye Surgery
Family History Has anyone in your family had any of the following? Please note relation to patient: 
F - Father, M - Mother, P - Paternal, MA - Maternal, S - Sister, B - Brother, GF - Grandfather, GM - Grandmother
Yes No Medical Condition Relation(s)
Cataracts
Retinal Disorder
Glaucoma
Heart Disease
Diabetes
Hypertension
Other Eye Problems
Other General Health Problems
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