Patient Forms – D'Sol Optical

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440 Patrol Road Jeffersonville, IN 47130

Contact Us 812-288-9898

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Visit Us Business Location

440 Patrol Road Jeffersonville, IN 47130

Email Us dsoloptical2020@yahoo.com

Call or Text Us 812-288-9898

Fax Us 812-288-5752

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Visit Us Business Hours

Monday 9am - 6pm

Tuesday 9am - 6pm

Wednesday 9am - 6pm

Thursday 9am - 6pm

Friday 9am - 2pm

Saturday Closed

Sunday Closed

How can we help you?

Select an option from our menu or connect with us in person!

Home D’Sol Optical
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new or existing customer

Patient Forms Portal

Click on the form below to get started.

Patient Forms New Patient

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D'Sol Optical

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Accepted Payment Methods

CareCredit Accepted

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Call Us 812-288-9898

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How can we help?

Use the form below to connect with us and let us know what services or needs you have.

Name *

First

Last

Layout

Phone *

Email

Comment or Message *

Required Field(s)

Get Started

Request an Appointment

Select a Date

Select a Time Range

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Patient Type *

Appointment Type *

Appointment Date *

Appointment Time *

Message

Required Field(s)

Billing & Payments

Pay your Invoice

Use the form below to pay your outstanding invoice balance. Simply enter the total amount to pay, your credit card information and click the Pay Now button. It’s that easy!

Name *

First

Last

Email *

Phone *

Date of Birth *

Billing Address *

Address Line 1

City

State

Zip Code

Invoice Number(s) (optional)

Enter one or more invoice numbers comma separated.

Payment Amount *

Message (optional)

Required Field(s)

Rate Your Experience

How was your Experience?

Click on the number of stars you would give your experience with us.

Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

New or Existing Customer?

Patient Forms Portal

Patient Forms New Patient

Patient Forms Existing Patient

Request Your Refill

Order Contacts

Use the form below to request your contact refill. Simply enter your information below and click the Submit button. It’s that easy!

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Patient Type *

Last Contact Lens Exam Date (optional)

Insurance? *

Primary Insurance Name *

# of Boxes

Brand of Contacts

Pickup or Delivery *

Shipping Address *

Address Line 1

City

State

Zip Code

Upload Your Prescription

Click or drag a file to this area to upload.

Message

Required Field(s)