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(479) 631-8900

At Jeffries Eye Associates, we value your time. In an effort to save you time in our office, you can download and complete the seven (7) patient forms we require prior to your appointment.  Please complete these forms to help us know the history and current state of your eyes and your health.  

Bring the completed forms, your insurance card(s), a picture ID and your medication list to your appointment.  Some insurances require a referral for medical eye care; verify with your insurance company if you are not sure.  We do not bill for "routine vision care"; only for medical care.

We have a waiting list for new patient exams; therefore, please give us at least 24 hour notice if you must reschedule.  

As a new patient, you will most likely be dilated in both eyes.  It is recommended you bring a driver if you are unsure if the dilation will affect your vision.  The dilation typically lasts up to six hours and in some patients, even longer.  You may want to bring sunglasses if you have them or we will give you a pair of disposable sunglasses at the end of your exam.

We look forward to serving you as our patient.  Thank you for choosing our office for your medical eye care.

  • You will need AdobeReader® to download the forms. Click below to download.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Bring the completed form(s) to our office with you to your appointment.

1.  New Patient Information Form

Download & Print Form


2.  Medical Records Release Form

Download & Print Form


3.  Patient Financial Form

Download & Print Form


4.  Notice of Privacy and PHI Form  

Download & Print Form


5.  Health History Form

Download & Print Form


6.  Allergies & Medication Form

Download & Print Form


7.  Review of Systems Form 

Download & Print Form


Download the Free AdobeReader®

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