Envisionoptique@1 - EO Consent

Today’s examination will evaluate the internal health of the eyes. This important assessment is essential for the early detection of eye problems such as DIABETIC EYE DISEASE, MACULAR DEGENERATION, GLAUCOMA, or PRE-CANCEROUS AREAS. All comprehensive examinations require an internal health assessment as part of the evaluation.

DILATION OF THE PUPILS - a procedure where eye drops are used to enlarge the pupils and view the internal health. This allows a thorough check, and will result in temporary reduced vision. Vision for driving and especially reading may become blurry, and the eyes will be sensitive to light for about 3-4 hours. Dilation is best if there is suspected eye disease, or for new patients. This can be rescheduled if needed. Disposable sunglasses are available upon request.
There is no additional fee for this test.

WELLNESS SCAN - a digital imaging technology that uses reflected light waves to obtain information about the back of the eyes. This procedure quickly captures a high-resolution scan as well as detailed photo of each eye, usually without the need for dilation. The Wellness Scan is a comfortable way to have a digital record of the back of the eyes. Certain patients with small pupils or eye disease may still need to be dilated and/or photos taken.
There is an additional fee of $45 for this test, which may be covered by routine vision benefits.

Please check one:

I would like a DILATION at this time and understand my vision may be impaired temporarily.I would like a WELLNESS SCAN, and understand dilation may be necessary if eye disease is found.I will RESCHEDULE an appointment for the dilation at a future date.I DO NOT WANT to have my eyes dilated at this time because (fill below). I understand that I am releasing this office from any legal claims or liability by not having the dilation.

I DO NOT WANT to have my eyes dilated at this time because ........................

PRIVACY, BILLING, AND COVID-19 POLICY - Please initial

Initial*   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.
Initial*   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.
Initial*   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.
Initial*   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*

INTERNAL EYE HEALTH EVALUATION