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Retinal Exam Form

Retinal Exam Form

DILATED FUNDUS EXAMINATION

Dilation enables the doctor to examine the eye for cataracts, glaucoma, and other conditions that may result in loss of vision. Early signs of diabetes, arteriosclerosis, and high blood pressure can be detected. In addition, the doctor can examine the retina for any holes, tears, detachments, or tumors.

In order to dilate the eyes, drops are instilled which widen the pupils within 15-20 minutes. Your vision, especially reading vision, may become blurred for about 4-6 hours. Dilation also has a tendency to make your eyes more sensitive to light, so disposable sunglasses are available to ease the glare from the sun.



--OR--

OPTOMAP + OCT RETINAL EXAMINATION

An Optomap provides your doctor with a view of approximately 82% of your retinal in a single photo capture and helps your doctor to evaluate your vision health The OCT is non-invasive and uses light to capture thickness and details of the optic nerve and layers of the retina. An Optomap + OCT Retinal Exam is fast, painless, and does not require dilating eye drops. Early signs of macular degeneration, diabetes, and hypertension can be detected, in addition to eye birth defects and retinal tears, holes, detachments. A benefit of an annual Optomap + OCT Retinal Exam is a permanent record to compare and track potential eye diseases.

Would you be interested in a complete dilated examination or the Optomap + OCT Retinal Exam?*

I have read and understand the above information.

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