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James Dugas, OD and Associates

Optometrists in Austin Texas
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Patient Paper Forms
It is more convenient to complete Patient Foms Online.  If you prefer to complete paper forms, use Fom #1 and Form #2. 
 
Paper Forms You Can Print and Complete Later
  • If you are a New Patient to Dr. Dugas complete Forms #1 and #2.
  • If you are a Former Patient and have not seen Dr. Dugas at the 1000 W. 39th St.office or have had a change in address or personal information, complete Form #1.
 
Patient Information 
Form #1 Patient Information Form    PDF file, 99 KB, 2 pages
This form provides our clinic with demographic and insurance information that we're required to keep on file in your medical record.  It also includes an Authorization to Release Information and an Acknowledgement that you have read the Notice of Privacy Pollicies. 
 
Medical History   
Form #2 Patient Medical History Form    PDF File, 138 KB, 2 pages
 
 
Other Forms and Information 
Notice of Privacy Policies  (on website)
The Federal Health Information Portability and Accountability Act of 1996 (HIPAA) requires that our clinic inform you of how we use, disclose and maintain the privacy of all the information we collect about you as our patient.  We ask that you read this document.
 
Authorization to Release Patient Records    PDF File, 8 KB, 1 page
This form is to be used if you would like your past provider to release your medical and/or prescription information to our doctor, or in the event that you would like our doctor to release your medical record and/or prescription information to another provider.  If this is your first visit to our clinic and you have had an eye exam within the past three years, we ask that you complete this form.
 
 
Laser Eye Surgery
Welcome to Eye Lasik    PDF File, 220 KB, 5 pages
Instructions regarding laser surgery and what to expect.  What to do before and after the procedure.
 
 
 
 
 
Forms1