Optomap Consent WHAT IS OPTOMAP® AND WHY IS IT NECESSARY?Name(Required) First Last The Optomap° is state-of-the art imaging technology that allows your doctor to examine the layers in your retina digitally (similar to a photograph, but more complex). Signs of sight and life threatening diseases such as macular degeneration, glaucoma, retinal detachments, cancerous tumors, diabetes and high blood pressure are but a few of the conditions that can be detected with this technology. When complemented with (and sometimes without) pupil dilation, the Optomap improves your doctor's ability to assess the health of your eyes - something that is important even if you are healthy. Parents: the Optomap is especially useful for children, who can sometimes be difficult to thoroughly examine. The Optomap is quick, painless, and will be saved as a permanent part of your patient record.BECAUSE OF THE ADVANCED DISEASE DETECTION: OUR DOCTORS RECOMMEND THAT YOU OBTAIN AN OPTOMAP EXAM EVERY YEAR. The Optomap exam typically is not covered by insurance, and is provided for a fee of $39. The Optomap produces a single 200° ultra-wide field image of the retina, allowing your doctor to see more of your retina at once than ever before. Yes, I would like an Optomap® performed today. Unsure, please tell me more. No - I decline - Understanding that the Optomap® images greatly enhance my doctor's ability to comprehensively examine my eyes. To have a thorough evaluation of my eyes today, I am prepared to have my pupils dilated. Signature If minor, parent/legal guardian must sign and dateDate MM slash DD slash YYYY Δ
