New Patient History Questionnaire Step 1 of 8 0% Name*(as it appears on your insurance) First Last What name do you prefer to be called? Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Cell Phone*Home PhoneCan we remind you of your appointments via text?* Yes No Verizon customers please check here Please be aware that your carrier has security measures that block your receipt of automated messages (such as appointment reminders, and notification of eyewear status) from our third party communication platform.Email* *Don’t worry, we will not send you any advertisingDate of Birth* MM slash DD slash YYYY Gender* Male Female Marital Status* Single Married Separated Divorced Occupation How did you hear about us? My insurance Another Doctor Word of mouth Google Who can we thank for your visit?* Examination InformationReason for today's exam* Routine Wellness Visit Medical Sick Visit Routine Wellness Visit: Glasses Contacts Annual Eye Exam Failed Screening Medical Sick Visit: Red Eye Eye Pain/Discomfort Eye Discharge Tearing/Dryness/Something in eye Headache Eyelid Bump/Swelling Lasik Pre/Post Op. Cataract Pre/Post Op. Glaucoma Vision Loss/Blur Flashes/Floaters Diabetic eye exam Other: Please check what level of treatment explanation that you would like. Tell me everything. Give me the basics. None. Just fix it. Insurance InformationPlease alert the front desk if you have more than one medical or vision insurance. We will need all medical cards.Who is the primary on your insurance?* I am Someone else is I AM NOT USING ANY INSURANCE and expect to pay for my services at the time they are rendered. Employer* Primary on Insurance* Your Social Security* What’s their information?Is their address the same as yours?* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Name* First Last DOB* MM slash DD slash YYYY Employer* Social Security* Gender* Male Female Upload Insurance Card Drop files here or Select files Accepted file types: jpg, png, gif, pdf, Max. file size: 3 MB, Max. files: 2. Please upload pictures of the front and back of your insurance card. Please hand current insurance cards to the front desk when you arrive for your appointment. Once you've done that, we don’t need anything else to file your insurance! Please note: FAILURE TO PROVIDE CURRENT INSURANCE INFORMATION PRIOR TO SEEING THE DOCTOR MAY RESULT IN A REJECTED CLAIM, AND YOU WILL LIKELY GET A BILL! Current Glasses and Contacts InformationGlassesDo you wear Glasses?* No Yes When do you need them?(Check all that apply) For far away Computer Reading/Close work What kind of glasses are they? Far away only Reading only Bifocal/progressive/Multifocal PLEASE BRING YOUR GLASSES WITH YOU TO YOUR APPOINTMENT.* Acknowledged I can't, they're lost How old are they?(years) ContactsDo you wear Contacts?* No Yes If you have any problems with vision or comfort in your current lenses, please describe it here Have you been told by other doctors that you cannot wear contacts? Yes No Have you attempted to wear them in the past and were unsuccessful? Yes No Was the lack of success due to Comfort Vision Unable to insert and remove the lenses Other Other Are you still interested in wearing contacts? Yes No PLEASE BRING EITHER BOXES OF YOUR CURRENT CONTACT LENSES TO YOUR APPOINTMENT, OR A WRITTEN COPY OF YOUR MOST RECENT RX.* Acknowledged How often do you wear them?* Everyday Occasionally How often do you throw them away?* 1 day 2 weeks 1 month When they get old What brand are they? Medical ConditionsDo you currently have any of the following conditions:* None Connective Tissue Disorder Arthritis Asthma COPD Diabetes Hepatitis Steven-Johnson’s Syndrome Sjogren’s Syndrome Cancer Pregnant / Breastfeeding Hypertension High Cholesterol Hyperthyroid Hypothyroid Seizures What is the name of the doctor that manages this condition?First NameLast NamePhoneFax Type of Cancer Ocular ConditionsDo you have or had any of the following conditions:* None Ocular Allergies Cataracts Diabetic Retinopathy Dry Eye Glaucoma Corneal Ulcer Cataract Surgery Strabismus Surgery LASIK / PRK Macular Degeneration Ophthalmic Migraine Retinal Tear/Detachment Strabismus (Lazy eye) Floaters Which year did you have Cataract Surgery? Which year did you have Strabismus Surgery? Which year did you have LASIK / PRK? Current MedicationsMy Medications* I do not current take any medications I will provide a written medication list upon my arrival to the office at the time of my appointment I will provide a list of all medications on this form Please list ALL MEDICATION that you CURRENTLY take. If you have a written list, just turn it in instead of this section.For example: Brand Name: "Advil"; Generic Name: "Ibuprofen"; Dosage: "100mg"; How many: "1"; Day/week/month: "Every day"; Cap/Tab/Solution: "Tablet"; Reason: "Pain"Brand NameGeneric NameDosage (mg)How manyDay/week/monthCap/Tab/SolutionReason Your Preferred Pharmacy CVS Publix Rite Aid Wal-Mart Kroger Walgreens Target Dollar Other Pharmacy Location and Phone Number* Allergies No known drug allergies Adhesive Silicone Latex Penicillin Sulfa Drugs Lidocaine Codeine/Morphine Medical Dye Other Medical Dye: Other: Social HistoryPlease note that this information is kept strictly confidential.Do you use Tobacco? No Occasional smoker Yes Former smoker Number of packs a day? Number of years smoking: Number of years that you smoked: Number of years since you quit: Family HistoryPlease check the box if anyone in your family has or has had any of the following:Amblyopia Father Mother Brother Sister Glaucoma Father Mother Brother Sister Macular Degeneration Father Mother Brother Sister Retinitis Pigmentosa Father Mother Brother Sister Diabetes Father Mother Brother Sister Connective Tissue Disorder Father Mother Brother Sister High Blood Pressure Father Mother Brother Sister * Unknown: Adopted None Other: We pride ourselves on providing our patients with the best possible standard of care. Because of this, we now perform the Optomap® Retinal Exam on all of our patients during each annual eye exam. The Optomap allows our doctors to capture an image of the back of your eye where potential vision threatening diseases can be found. This includes diabetes, glaucoma, certain types of cancer, retinal tears, and cardiovascular issues. Also, you will not need to be dilated after the Optomap is captured. As part of your pre-test work up, we will capture optomap® images for review with the doctors during your examination today. There is a $39 co-pay for the Optomap after applying your insurance benefits. Any questions you have about the Optomap® Retinal Exam can be directed to Dr. Huffman or Dr. Vazquez when they review the images with you during your exam. Terms* I have read and understood this document and look forward to my Optomap $39 I have read and understood this document and would rather receive traditional dilation with drops Patient Agreement of Consent to Treat and Office Policies • I consent to such care and treatment as prescribed by the doctor as is necessary in his medical judgment. • I acknowledge that if I receive a contact lens exam and do not return within 90 days of the original exam for my corneal evaluation fitting and follow up I will be charged for my fitting and another refraction a second time and it will not be billed to my insurance company. • All copays are collected at the time of service. Payment is required, at time of order, for all materials. I understand that I am financially responsible for charges not covered by my insurance company. If I do not give necessary information to process my health/vision insurance in a timely manner, I will be responsible for those charges. • Insurance Disclaimer: “A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.” UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED • I have been made aware that there are no refunds given, for any materials, after the 30 day manufacturer’s warranty expires and/or is subject to my vision insurance policies. No refunds are given for any services once they are rendered. A restocking fee will be charged for any eyeglass order cancelations. I acknowledge that I have received a copy of the Huffman Family Eye Care Notice of Privacy Practices.Patient Signature or Patient’s Legal RepresentativeDate MM slash DD slash YYYY Patient’s name First Last Records ReleaseCertain circumstances dictate to whom we can and cannot share your information with. If any of the below situations apply to you, please indicate and be aware that additional paperwork may be required. I am over 18 yrs old and authorize my parent to be involved with, or informed of my care and any balances accrued. This patient is a minor (under 18) and the child of divorced parents that do NOT share custody. You may NOT release information to the person specified below. The patient has released power of attorney to an adult child or caregiver to act on their behalf. You may NOT release information to: Name First Last Phone
