Family History (other than yourself): (please check applicable family members)
Social History: (please select all that apply)
Contact lens patients please provide:
At standard the optical of shop, we pride ourselves in providing our patients with the best possible care. Because of this, our doctors strongly recommend that all patients have an Optomap Retinal Exam. This non-invasive procedure allows your doctor to see a much broader and detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Our doctors believe that the Optomap Retinal Exam is an important part of your comprehensive eye exam and offer it to all patients every year.
This imaging device allows the doctor to detect retinal abnormalities, glaucoma, macular degeneration as well as other health conditions such as diabetes, high blood pressure, cholesterol, tumors, and other life-threatening diseases.
*Please Note: The Optomap Retinal Screening Exam is not covered under your basic health plan, meaning that your are responsible for the charges. Our fee for the retinal screening, measurement and interpretation is $35.00. We will collect this fee along with your co-payment and deductibles at the end of your visit.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.