Allisonville Eye Care Center – Consent for Testing

Allisonville Eye Care Center - Consent for Testing

Thanks for Trusting Us with YOUR Eye Care*
- I would like a comprehensive eye examination only (provides a glasses prescription only)
- I would like to be evaluated for Orthokeratology in addition to my comprehensive eye examination* *No additional fees apply
- I would like to be evaluated/fit to wear contact lenses or have my contact lens prescription renewed** **Additional fees apply and will differ based on the level of complexity
Digital Retinal Imaging
Digital retinal imaging allows us to take digital photographs of your retina (the back of the eye). This procedure assists the doctor in the early detection of many diseases and gives us a permanent picture to compare at future exams. The doctor recommends retinal photographs are taken as a baseline on all patients. The process is quick, painless and nothing touches the eye. The doctor will review the results with you. The fee for screening retinal photographs is $39. **Although this is an optional test for some patients, it represents preventative healthcare for others and photo-documentation is required because of certain eye/health conditions that may be present and need to be closely followed. In the latter case, more extensive photographs may need to be taken. We will then submit the procedure to your major medical insurance and you will be responsible for any copays/deductibles.** Please check the appropriate box and sign:*
- Yes. I want retinal photographs taken of my eyes.
- No thanks. I do not want retinal photographs taken of my eyes
Visual Field Screening
The visual field screening tests the integrity of the optic nerve pathway as it passes from the eye into the brain. It is a non-invasive computerized test which helps detect early signs of glaucoma, optic nerve disorders, retinal diseases and even certain brain tumors which can not be detected during a normal eye examination. We recommend this test is performed yearly on all patients 5 year of age and older. Most insurance does not cover this procedure, but we are happy to provide this test for $10. Please check the appropriate box and sign:*
- Yes. I would like the visual field screening
- No thanks. I would like the general eye examination only (without visual field screening)
Signed*
For child (if appropriate)
Date*
Date Format: MM slash DD slash YYYY
Dr. Karres strongly recommends that the 2 tests above are done annually. To help with the cost associated with the tests we will apply a $5.00 discount when you choose to have both tests done the day of your exam!