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Eye Exam & Dilation Online Form

Eye Exam & Dilation Online Form

OPTOMAP DIGITAL TECHNOLOGY IS COMPLETELY SAFE

Retinal problems such as macular degeneration; glaucoma, retinal holes, retinal detachments and diabetic retinopathy can now be seen without dilation for most patients. All of our doctors recommend ALL patients have a digital image annually with the new state-of-the-art scanning digital imaging system. Early detection is crucial!

Dilated Eye Exam

Optomap Eye Exam

Do you choose to have an Optomap eye exam?*

CONTACT LENS AGREEMENT

The contact lens evaluation is an additional $55-85 fee to the yearly comprehensive eye exam, which includes a glasses prescription. The evaluation includes all necessary follow ups, trial contact lenses and sample solution within the first 60 days. After the first 60 days, there will be a $30 fee for each additional visit. Contact lens evaluation fees are non-refundable.

The evaluation consists of determining the proper lens type and fit based on the curvature of your eyes, determination of correct contact lens prescription, as well as checking the clarity of vision and fit of the lens. Like glasses prescriptions, contact lens prescriptions need to be updated yearly. Many times, your contact lens prescription will be different than your glasses prescription. Additionally, and most importantly, you will be assessed for any health issues associated with contact lens wear.

HIPAA PRIVACY POLICY PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  1. Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  2. Obtaining payment from third party payers (i.e. my insurance company)
  3. The day to day healthcare operation of your practice
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We offer a wide variety of eye care services to the Austin community. Contact us with any questions about our services.

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