As part of a comprehensive eye examination, it is recommended that all patients have the internal health of their eyes thoroughly evaluated every year. This is performed as either a dilated retinal exam or the Optomap retinal imaging, the most advanced technology in retinal screening.

The Optomap is fast, easy, and comfortable. The screening results are a permanent part of your medical record. It allows the doctor to detect diseases affecting both the eyes (glaucoma, macular degeneration) and the body (high blood pressure and diabetes). The doctor will review the photograph with you in the exam room.

Normal Optomap screening results allow you to avoid dilation drops, which result in blurred vision and sensitivity to light for 4-6 hours.

Your insurance is designed to cover a basic eye exam, it does not cover advanced screening tools such as the Optomap. The doctors at our office strongly believe it is in your best medical interest to have the Optomap retinal scan. The Optomap screening fee is $42, your vision benefit reduces it to a $39 copay.

I have read and understand the above, and agree to the Optomap Retinal Exam.
I have read and understand the above, and decline the Optomap Retinal Exam but wish to have my eyes dilated.
I have read and understand the above, and decline both the Optomap Retinal Exam and a dilated eye exam at this time. I acknowledge that I am foregoing the testing required for the optometrist to diagnose serious visual conditions.

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