Envisionoptique@1 - EO Consent

Envision Optique now offers a new state-of-the-art diagnostic procedure called Digital Retinal Imaging. This is an extension to the comprehensive eye examination which captures an image of the inside (retina) of your eye using a high- definition digital camera. Digital imaging can aid in the early detection of eye diseases such as DIABETIC RETINOPATHY, MACULAR DEGENERATION, GLAUCOMA, PRE-CANCEROUS LESIONS AND RETINAL HOLES OR BREAKS. We highly recommend this procedure for all of our patients. While digital imaging is not always a replacement for dilation, it is a comfortable and non-invasive way to document a normal healthy retina at a given time. Some patient may still need to be dilated and photos taken if eye disease is detected.

There is a nominal fee of $40 for this test, which is not covered by routine vision benefits.*

I DO want to take the test at this timeI DO NOT want to take the test at this time

DILATION OF THE PUPIL is a procedure where eye drops are used to enlarge the pupils. This allows Dr. Obregon to check for eye diseases and conditions that may result in loss of vision. Your vision for driving and especially reading may become blurry, and your eyes will be sensitive to light for about 3-4 hours. Disposable sunglasses are available upon request. There is no additional fee for this test.

Please check one:*

I AM TAKING DIGITAL PHOTOGRAPHS and understand dilation may be necessary if eye disease is found.I DO NOT want to have my eyes dilated at this time because

I understand that I am releasing this office from any legal claims or liability by not having the exam.*

I WILL RESCHEDULE an appointment for the dilation at a future date.I DO want to have my eyes dilated at this time and understand my vision may be impaired.

*

I hereby acknowledge that I have received, or had the opportunity to review a copy of the privacy practices of Dr. Michael R. Obregon, OD PA, doing business as Envision Optique.

*

I hereby authorize this office to release any information needed to bill for and expedite insurance claims, and I understand that I am responsible for all charges not covered by my vision or medical insurance.

*

I understand all appointments made by me constitute reserved time set aside for me and that any changes require a minimum 24 hour notice. Missed appointments are subject to a $50 missed appointment charge.

*

I understand that if I am sick, have a cough or fever, I will be asked to reschedule my appointment. I have not been in contact with or otherwise exposed to persons with COVID-19 to the best of my knowledge.

I have read this document and have had the opportunity to ask any questions I might have regarding its contents. My signature below indicates full understanding and acknowledgement of the options and policies described above.

Patient/Parent Signature*

Clear

Date*

Date

Patient Name*

DIGITAL RETINAL IMAGING INFORMED CONSENT

DILATED FUNDUS EXAMINATION INFORMED CONSENT