Patient Annual Consent Form

Thank you for choosing our office to provide you with your eye examination.

Parents: Please DO NOT complete and/or sign form for ADULT children (18 years old and older). We need all legal adults to legally consent and sign the form themselves. Thank you.

Patient Name*

First NameLast Name

Date of Birth*

Date

Last 4 Digits of SSN

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Cell Phone Number

Secondary Phone Number

Secondary Phone Number is:

WorkHome

Pronoun

Marital Status

Please list the names of any individuals that you give us permission to discuss any and all vision and medical information with, as well as any other information, including financial, pertaining to your account.

Individual 1

Individual 1 Relation to Patient

Individual 2

Individual 2 Relation to Patient

Individual 3

Individual 3 Relation to Patient

AGREEMENT TO RECEIVE TEXT MESSAGING COMMUNICATIONS

Our office utilizes electronic notification system (email, text messaging) to notify our patients of appointment reminders, glasses and contact lenses pick up, office closures, scheduling conflict, etc. There is some level of risk that third parties might be able to read unencrypted text messages. It is your responsiblity to provide Huntley Eye Care, L.L.C.with any updates to your cell phone number.

Please select below*

I AGREE to give permission to text messaging communications. Text messaging rates may apply.I DECLINE text messaging communications. (Withdrawal of text messaging may delay pertinent information, i.e.appointment reminders, office closure, eyewear pick up)

DIABETIC EYE EXAM

Do you have diabetes OR are you currently being treated or monitored for diabetes (OR will you need an eye exam report to be sent to your medical doctor regarding your diabetes)?

Select an option below:*

NoYes (Your eyes will have to be dilated at the exam)

Due to the medical/diabetic concern, your visit will have to be billed to your medical insurance (not a wellness vision plan, such as VSP or EyeMed). If you are needing a routine glasses or contact lens check up (and have a vision plan), that visit will have to be scheduled on a separate day after your diabetic eye exam.

Name of Medical Insurance

Insurance Group and ID Number

Name of Insured

First NameLast Name

Insured Date of Birth

Date

iWELLNESS SCREENING

This screening is HIGHLY RECOMMENDED and serves a tremendous role in assisting the doctor with a more thorough assessment of the patient's ocular health and in detecting early signs of glaucoma, macular degeneration, diabetes in the eye, etc. The screening will capture a digital retinal image of the patients eyes as well as a scan of the retinal tissues below what is normally visible to the doctor. There is only a fee of $45 that is not billable to any medical insurance or vision plan and will be the responsibility of the patient. The screening is safe and harmless to the eyes and this allows the doctor to dectect subtle changes in your eyes over time so yearly screening is highly recommended.

Select an option below:*

I AGREE to the iWellness Screening.I DECLINE the iWellness Screening.

DILATION

The dilation will enlarge the pupils of the eyes so the doctor can view structures in the back of the eye. The side effects are blurred near vision and light sensitivity for a 3-4 hours. In some patients, distance vision and driving may also be affected. Patient will need to remain in the office for additional 30-45 minutes for the dilation to be completed.

Select an option below:*

I AGREE to the dilation and UNDERSTAND the side effects can temporarily hinder my vision from performing certain tasks and activities.I DECLINE the dilation.

CONTACT LENS EVAULATION

Contact lenses are FDA-regulated medical devices. A contact lens evaluation is necessary to monitor changes to the health of your eyes from utilizing these devices. There is an increased risk of infection and/or corneal ulcers that can lead to loss of vision with contact lens wear. Therefore, an annual evaluation is necessary if you would like to continue wearing, replacing, and/or reordering your contact lenses. The evaluation includes the initial evaluation, the use of diagnostic lenses, and any contact lens prescription-related follow-up visits within 60 days. Any office visits greater than 60 days or any office visits within 60 days that is not contact lens prescription-related (i.e. red eye) will be charged a separate office visit fee. (Length of coverage may vary with vision plan.)

Select an option below:*

I AGREE to a contact lens evaluation. My vision plan and/or medical insurance may or may not cover this evaluation. I agree to pay for the evaluation at time of service. I understand the contact lens evaluation fee is a professional service and is non-refundable, even if I decide not to go forth with contact lens wear after the diagnostic lens trial period.I DECLINE a contact lens evaluation. I understand that if I have a contact lens prescription and it is expired I will not be able to order any more contact lenses without a contact lens evaluation.

I am currently:

Previous contact lens wearerNew contact lens wearer and will need insertion and removal training

Financial Agreement

INITIAL to agree to: I have reviewed, understand, and agree to the terms and financial responsibilities as noted in the "Financial Agreement" of Huntley Eye Care, L.L.C.*

If patient is a minor, guarantor (person who will be financially responsible for account) will default to parent/legal guardian accompanying patient on day of exam.

Notice of Privacy Practices

INITIAL to agree to: I have reviewed and understand the "Notice of Privacy Practices" of Huntley Eye Care, L.L.C.

On the day of your exam, please remember:

If you are not feeling well we ask that you kindly reschedule your appointment for the well-being of all our staff and patients. (You will be asked to reschedule if you show any symptoms on the day of your appointment)
Cancellation made less 24 hours of appointment time will incur a $50 cancellation fee.

Also please bring with you:

Insurance cards (Medical and Vision)
Driver's license (or another form of photo identification)
Prescription eyeglasses (or copy of current eyeglass prescription)
List of current prescription medications

Patient Signature*

Name of person signing Consent Form *

First NameLast Name

Relation to patient

Today's Date*

Date