Optomap Agreement Form

Early signs of disease in the periphery of your retina can remain undetected when using traditional methods. The Optomap image is a unique technology that allows us to scan 80% of your retina in one panoramic image, without dilation. For this reason, our doctors strongly recommend that all patients have the Optomap procedure performed annually.

• Allows our doctors to track your complete eye health for concerns.
• Facilitates early protection from vision impairment or blindness.
• Early detection of retinal disease more effectively and efficiently.
• Early detection is essential to reduce the risk to your sight and health.
• Please Check One of the Following:
  • I choose to have the Optomap scan. I understand that based on the doctor’s assessment of the retinal scan and examination, dilation may still be recommended. I understand there is a $25.00 fee for this scan.
  • I choose to be dilated today. I understand that after dilation, my vision may be slightly blurry when reading and might be light sensitive for 3-4 hours.
• Print Patient Name
• Signature of Patient/Guardian
• Date
• Relationship to Patient (if signed by someone other then patient)