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.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pronoun*
Marital Status*
Email
example@example.com
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.
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. 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.
Cell Phone Number
Please select below*

I AGREE 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)
FINANCIAL AGREEMENT*

I agree to assume all financial responsibilities as noted in the "Financial Agreement."
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*

I have been presented with and understand the "Notice of Privacy Practices" of Huntley Eye Care, L.L.C.
DIABETIC EYE EXAM

Do you have diabetes or are you currently being treated or monitored for 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 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.
Name of Medical Insurance
Insurance Group and ID Number
Name of Insured

First NameLast Name
Insured Date of Birth

MonthDayYear
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 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.
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. 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.
Select an option below:*

I AGREE to the dilation. (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.)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.
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
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.)
Within the last 30 days, have you been diagnosed with COVID-19?*

NoYes
If yes, Date of positive test:

MonthDayYear
Date
Do you currently have a pending COVID-19 test and waiting for results?*

NoYes
Within the last 30 days, have you or any member of your household been asked or required to quarantine based on contact with a person who has a confirmed or a presumptive positive COVID-19 test result or diagnosis?*

NoYes
If yes, First day of quarantine:

MonthDayYear
Date
Within the 14 days prior to your scheduled appointment date, have you or any member of your household had close contact with or cared for someone who has a confirmed or a presumptive positive case of COVID-19?*

NoYes
Within the 14 days prior to your scheduled appointment date, have you experienced any of the following symptoms? (Check ALL that apply)*

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaNone of the above
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
Patient Signature*

Clear
Name of person signing Consent Form *

First NameLast Name
Relation to patient
Today's Date*

MonthDayYear
Date
Should be Empty: