Accent Eye Care Returning Patient

Name

First Last

Date

Email

(for yearly reminder purposes only)

Please Review Your Last Patient Information Form, are there any changes to:

Address

Phone Number

Insurance

Medical History

Medications

Reason for today's visit:

DILATED EYE EXAMINATION:

This testing is the most effective way to evaluate the internal health of the eyes. We strongly recommend this test to all of our patients. The dilated eye exam is covered by many, but not all insurances.

PLEASE CHECK ONE:

I ACCEPT DILATION
I DECLINE THIS TEST

DIGITAL RETINAL IMAGING

• Procedure: Retinal imaging is the best way to keep an accurate record of your inner eye health. • When to do this test: lf you have no risk factors for eye disease our doctors recommend images be taken at your first eye examination and then every 1-2 years thereafter. If you have risk factors for eye disease or are over 40 years old, we recommend taking retinal photos yearly to monitor any changes to your retina (glaucoma, macular degeneration, retinal thinning/detachments, melanoma, etc.) • Benefits of Digital Retinal lmaging: Early detection and treatment of eye problems and disease. • Side effects of Digital Retinal Imaging: NONE. • Fee: Digital Retinal Imaging is covered by many, but not afí insurances. Please inquire at front desk if you are unsure if your insurance covers this procedure. If not covered, the fee is $39.00

PLEASE CHECK ONE:

I ACCEPT RETINAL IMAGING
I DECLINE THIS TEST

SIGN NAME:

I have reviewed patient information forms, dilated eye exam, visual field, and authorization and assignment sheets from previous visits and made any changes above.