Patient Retinal Photography Form

Retinal photography is used to detect and evaluate conditions such as macular degeneration, retinal detachment, diabetic retinopathy, or glaucoma. By electing to have these photos taken, you are allowing our doctors to monitor the health of your eyes as well as the progression of any eye diseases. These photos provide us with a reference for comparison during future visits and allow them to provide you with the most thorough evaluation possible. If a medical condition is identified from these photos, we are able to file this procedure with your medical insurance company; however, if no medical diagnosis is found, we are unable to file the procedure and you agree to pay a fee of $39.00. New Patients, please email Patient Record Form as well.

Patient's Name *
Last Name *
Date of Birth
E-mail *
Procedure Consent
Yes, I would like to have this procedure.

No, I would not like to have this procedure.
Signature

Typing your name constitutes a signature
You may be asked to sign this form in the office to verify authenticity
Verify your entry *
Type: glasses