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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