• (Please Read Carefully: if you fail to indicate your preference, the default recommendation is #3, and you are responsible for all applicable charges) Retinal examinations allow our Doctors to see inside the eye and improve our ability to detect ocular conditions and diseases. The Doctors recommend at least one retinal exam annually for all patients of Dynamic Eye Care, even children. Please indicate your preference at the bottom of this form.

    1. Optomap Digital Imaging (Optomap). Optomap captures an image of 80% of your retina in perfect clarity. Compared to a dilated retinal exam, the Optomap helps us document, review and visually compare your retina over time. The procedure normally takes 5 minutes to complete. Because no eye drops are administered, there are no side effects normally associated with dilation (see #2 below). However, Optomap alone may not be an adequate examination. You must consult your Doctor first if you prefer Optomap with no dilation. The charge for Optomap is $39.00 in addition to your eye exam today. At this time, most health insurance plans do not cover this service and it is an out-of-pocket charge.

    2. Dilated Retinal Exam. Dilation of the pupil uses eye drops to allow the Doctor a view inside the eye to detect ocular conditions and diseases, although no images can be captured. Common side effects include light sensitivity for 4-6 hours and blurred vision especially at near distances. We recommend you have a driver accompany you, but most patients are able to drive themselves. Although side effects are rare, you should contact our office immediately if you experience eye pain, headache or nausea. If your health insurance plan includes routine vision services, most plans will cover an annual dilated retinal exam, subject to your deductible and co-pay requirements.

    3. Optomap and Dilated Retinal Exam. THIS IS RECOMMENDED BY THE DOCTOR FOR ALL PATIENTS. Studies have shown Doctors are 30% more likely to detect retinal disease when dilation is combined with digital imaging such as Optomap. This provides you and your Doctor the best tools to examine the overall health of your retina. The charge for Optomap is $39.00 in addition to your eye exam today, and this is most likely an out-of-pocket charge. As with #2, side effects from dilation may occur.

  • I have reviewed, understand, and been given the opportunity to ask questions regarding all testing described above for annual retinal examination, and I choose:

    (note: if no number is specified, I agree to the default recommendation of using Optomap and the Dilated Retinal Exam, and I am responsible for all applicable charges).

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