Patient Information Form

INSURANCE INFORMATION

MEDICAL AND OCULAR HISTORY

DO YOU OR ANY OF YOUR BLOOD RELATIVES (I.E. GRANDPARENTS, BROTHER OR SISTER) HAVE ANY OF THESE CONDITIONS?

OPTOMAP FORM DIGITAL RETINAL SCAN

TriState EyeCare Associates offers state-of-the-art digital scanning technology that allows us to view the inside of your eye without the use of dilation drops. The OPTOMAP allows our doctors to evaluate your retina for problems such as Macular Degeneration, Glaucoma, Retinal Holes, Retinal Detachments, Hypertensive / Diabetic Retinopathy, and much more. he scanning system is completely safe for children and adults~ It allows you the opportunity to see inside your eyes just as the doctor sees them!

We recommend that all patients have a thorough examination of their retina each year. There is an additional fee of $39.00 for the OPTOMAP scan. In most cases, this scan is not covered by insurance.

Dilation may still be required in some cases, such as Glaucoma or other conditions.

1. Blurred near vision for 4-6 hours

2. Light sensitivity for 4-8 hours

3 Longer office visit to wait for drops to take effect

4. Only the doctor can see the retina

1. No blurred vision

2. No light sensitivity

3. Scan takes less than 2 minutes

4. Digital image that can be reviewed I compared each year

5. You can see your retina