Patient Annual Consent Form

Patient Annual Consent Form
Welcome to Huntley Eye Care, L.L.C.! 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.
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
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 AND EMAIL 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 and it is your responsiblity to provide Huntley Eye Care, L.L.C.with any updates to your cell phone number. Text messaging rates may apply.
Cell Phone Number
I would like to receive (Please check ALL that apply): *

Appointment Reminders/Recall Visits Information Regarding General Office Updates/Hours/Closures/Patient Satisfaction Glasses and/or Contact Lenses Pick-Up Notification Decline all (Withdrawal of text messaging and email communications 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.
iWELLNESS SCREENING

It is highly recommended, especially during COVID-19, for the patient to complete our iWellness screening. This screening 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.
CORNEAL AND CONTACT LENS EVAULATION

Contact lenses are FDA-regulated medical devices. A corneal and 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.

At this time, due to COVID-19, we will not be doing any insertion and removal training; therefore, will not be able to perform a corneal and contact lens evaluation on any new contact lens wearer.
Select an option below: *

I AGREE to a corneal and 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 corneal and 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 corneal and contact lens evaluation. I understand that if my contact lens prescription is expired I will not be able to order any more contact lenses without a corneal and contact lens evaluation.
COVID-19 SCREENING
Within the last 30 days have you been diagnosed with COVID-19? *

No Yes
If yes, Date of positive test:

Month Day Year
Date
Date of negative retest:

Month Day Year
Date
Within the last 14 days have you experienced any of the following symptoms? (Check ALL that apply) *

Fever Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea None of the above
Have you traveled internationally in the last 14 days? *

No Yes
Have you or a member of your household had close contact with or cared for someone diagnosed with COVID-19 in the last 14 days? *

No Yes
Have you or a member of your household had close contact with or cared for someone with a presumptive positive case of COVID-19 in the last 14 days? *

No Yes
Has anyone in your household been asked or required to quarantine based on contact with a person who has confirmed or presumptive positive COVID-19 test result or diagnosis, or have you been asked to quarantine? *

No Yes
If yes, Last day of quarantine:

Month Day Year
Date
On the day of your exam, please remember:
- Face Mask is REQUIRED for entry.
- Please come ALONE to your appointment.
- Minor patients should be accompanied by ONE parent only , no other family members or siblings allowed.
Patient Signature *

Clear
Name of person signing Consent Form (if other than patient)

First Name Last Name
Relation to patient
Today's Date *

Month Day Year
Date
Should be Empty:

Patient Annual Consent Form

COVID-19 SCREENING