New Patient Form | Huffman Family Eye Care

Name(Required)
(as it appears on your insurance)
First Last
What name do you prefer to be called?
Address(Required)
Street Address Address Line 2 City State Zip
Home Phone(Required)
Cell Phone(Required)
Can we remind you of your appointments via text?(Required)
- 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(Required)

*Don’t worry, we will not send you any advertising
Date of Birth(Required)
Gender(Required)
- Male
- Female
Marital Status(Required)
- 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?(Required)

Insurance Information
Please 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?(Required)
- 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(Required)
Primary on Insurance(Required)
Your Social Security(Required)
What’s their information?
Is their address the same as yours?(Required)
- Yes
- No
Address(Required)
Street Address Address Line 2 City State ZIP Code
Legal Name(Required)
First Last
DOB(Required)
Employer(Required)
Social Security(Required)
Gender(Required)
- Male
- Female
Upload Insurance Card
Drop files here or

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!

Medical Conditions
Do you currently have any of the following conditions:(Required)
- 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 Name Last Name Phone Fax
Type of Cancer
Ocular Conditions
Do you have or had any of the following conditions:(Required)
- 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 Medications
My Medications(Required)
- 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 Name Generic Name Dosage (mg) How many Day/week/month Cap/Tab/Solution Reason
Your Preferred Pharmacy
- CVS
- Publix
- Rite Aid
- Wal-Mart
- Kroger
- Walgreens
- Target
- Dollar
- Other
Pharmacy Location and Phone Number(Required)
Allergies
- No known drug allergies
- Adhesive
- Silicone
- Latex
- Penicillin
- Sulfa Drugs
- Lidocaine
- Codeine/Morphine
- Medical Dye
- Other
Medical Dye:
Other:
Social History
Please 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:

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 with your vision insurance. 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.
(Required)
- I have read and understood this document and look forward to my OptoMap
- 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, and consent to signing this document electronically.
Date(Required)
Patient’s Electronic Signature(Required)
First Last
Records Release
Certain 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
Phone
This field is for validation purposes and should be left unchanged.

If you are a new patient, please fill out the form below.

New Patient History Questionnaire

Step 1 of 8

Examination Information

Insurance Information

Current Glasses and Contacts Information

Medical Conditions

Ocular Conditions

Current Medications

Social History

Family History

Patient Agreement of Consent to Treat and Office Policies

Records Release

Contact Us

Find Us

First Name	Last Name	Phone	Fax

Brand Name	Generic Name	Dosage (mg)	How many	Day/week/month	Cap/Tab/Solution	Reason