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Retinal Imaging Consent Form

Retinal Imaging Consent Form

  • As part of a comprehensive eye examination, it is recommended that ,ALL patients have the internal health of the eyes thoroughly evaluated every year. This is performed as either a dilated retinal exam or with Optomap retinal imaging.
    TSO doctors take pride in the quality care they provide for their patients and want to provide the most highly advance technology available in retinal screening. With an optomap screening doctors can uncover and document problems such as macular degeneration, glaucoma, retinal holes or detachments and diabetic or hypertensive retinopathy ( all of which can lead to partial loss or blindness).
    Optomap:
    • Provides an eye wellness scan
    • Gives depth to retinal layers (where diseases can start)
    • Provides a permanent record to your medical file
    • Fast, easy, comfortable with no down time.<.li>
    • Will NOT entail blurry vision or light sensitivity for 4-6 hours that is associated with dilation.

    • PLEASE NOTE THERE IS AN ADDITIONAL CHARGE OF $39.00 FOR THE OPTOMAP RETINAL EXAM WHICH IS NOT COVERED BY INSURANCE.
      *Certain conditions require dilation each year and would not qualify for Optos retinal imaging
    • Date Format: MM slash DD slash YYYY

Call for an Appointment, We are open!

We are making special arrangements with the current public health concerns. When you call TSO Bandera, we will space your appointment time to be mindful of social distancing and your personal comfort.

We kindly ask that you hold off on scheduling your appointment if…

  • You have traveled by plane in the last 3 weeks.
  • You have traveled out of the state or country in the last 3 weeks.
  • You are currently feeling ill or are having symptoms such as cough, fever, sore throat, ect.

Please call us in advance with any questions.

If you are a contact lens wearer with less than a 3 month supply, we encourage you to call in and place your orders to help avoid any possible future delays. Free shipping to your home address will be given with a 2 box purchase minimum.

When you schedule your eye exam appointment, you can have the extra confidence that you will be safe and comfortable at Texas State Optical.