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  • Patient Annual Consent Form

    Patient Annual Consent Form

  • Thank you for choosing our office to provide you with your comprehensive eye examination and all your eye care needs.

    To protect your privacy and in respect for others, please DO NOT USE your cellular device while in our office. 

    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.

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  • 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 information pertaining to your account.

  • 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. This is the most effective and efficient way to notify our patients. 

    By providing us with your cell phone number, you are giving us permission to communicate with you through text messaging. 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.

  • 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.

  • DIABETIC EYE EXAM

    Do you have diabetes or are you currently being treated or monitored for diabetes?

  • Due to the medical/diabetic concern, your visit will have to be billed to your medical insurance (not a routine 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.

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  • 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 any subtle changes in the eye. The screening will capture a digital retinal image of the patients eyes and allow for a scan of the retinal tissues below what is normally visible to the eye, which helps detect early signs of glaucoma, macular degeneration, diabetes in the eye, etc. The procedure is safe and harmless to the eyes and there is only a copayment of $44 for this procedure.

  • 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. Due to COVID, please also keep in mind, during this procedure you will be within 6 feet of the doctor for an extended period of time.

  • 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.

  • COVID-19 SCREENING

    (If the appointment is for a child, please answer the screening on behalf of the child AND the adult who will be accompanying the child to the exam.)

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  • On the day of your exam, please remember:

    • Face Mask is OPTIONAL (You will be asked to reschedule if you show any symptoms on the day of your appointment)
    • Only ONE parent will be allowed to accompany child in the exam room
    • NO siblings or other family members will be allowed in the exam room

    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
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