New Patient Form | Huffman Family Eye Care

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

Book Appointment

New Patient Form

Pay Online

New Patient History Questionnaire

Step 1 of 8

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

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)

Month

Day

Year

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)

Examination Information

Reason for today's exam(Required)

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 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

Address(Required)

Street Address Address Line 2 City State ZIP Code

Legal Name(Required)

First Last

DOB(Required)

Month

Day

Year

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!

Current Glasses and Contacts Information

Glasses

Do you wear Glasses?(Required)

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.(Required)

Acknowledged

I can't, they're lost

How old are they?

(years)

Contacts

Do you wear Contacts?(Required)

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

Have you attempted to wear them in the past and were unsuccessful?

Yes

Was the lack of success due to

Comfort

Vision

Unable to insert and remove the lenses

Other

Are you still interested in wearing contacts?

Yes

PLEASE BRING EITHER BOXES OF YOUR CURRENT CONTACT LENSES TO YOUR APPOINTMENT, OR A WRITTEN COPY OF YOUR MOST RECENT RX.(Required)

Acknowledged

How often do you wear them?(Required)

Everyday

Occasionally

How often do you throw them away?(Required)

1 day

2 weeks

1 month

When they get old

What brand are they?

Medical Conditions

Do you currently have any of the following conditions:(Required)

None

Connective Tissue Disorder

Arthritis

Asthma

COPD

Diabetes

Hepatitis

Steven-Johnson Syndrome

Sjogren’s Syndrome

Cancer

Pregnant / Breastfeeding

Hypertension

High Cholesterol

Hyperthyroid

Hypothyroid

Seizures

Type of Cancer

What is the name of the doctor that manages this condition?

First Name

Last Name

Phone

Fax

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. Select the "+" icon at the end of the row to add multiple medications.

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?

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 History

Please 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

(Required)

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 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.

Consent(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)

Month

Day

Year

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

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

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