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WHO NEEDS THIS TEST?

This is one of the newest technologies for helping doctors manage the health of the eye. Just as many other health professionals use MRI’s, mammograms or

X-Rays to aid in diagnosing health conditions, our office provides a comparable level of quality care called Digital

Retinal Imaging (DRI).

Because there are no nerve endings in the back of the eye that sense changes or pain, unwanted conditions may arise at any time which are totally undetected by you. The imaging is quick, easy and comfortable and allows us to examine, evaluate, and document the inner lining of the eye and the optic nerve.

We highly recommend Retinal Imaging for every patient and yearly imaging thereafter for further evaluation.

Retinal Images become part of your permanent medical record allowing us to compare and monitor any changes that may occur in the future. They also facilitate the early diagnosis of many health conditions including high blood pressure, macular degeneration, glaucoma and diabetic eye changes.

Retinal Imaging is strongly recommended for patients with a personal or family history of high blood pressure, diabetes, macular degeneration, glaucoma, retinal holes, or detachments.

WHAT CAN YOU SEE WITH RETINAL

IMAGING?

Digital Retinal Imaging is extremely useful in detecting eye diseases such as glaucoma, macular degeneration, and other retinal disorders, as well as detecting early signs of systemic diseases like diabetes and hypertension.

HOW MUCH DOES IT COST?

Most insurances and vision plans do not yet cover

Retinal Imaging. The fee for the Digital Retinal Imaging screening is only $30 .

Please note: If the Retinal Imaging shows a problem or potential problem, the photography is often covered by your major medical insurance. We will bill the full amount to your insurance as fundus photography and you will not be charged.

You will only be responsible for all applicable co-pays, coinsurance, and deductibles.

EARLY DETECTION AND TREATMENT OF EYE DISEASE IS CRITICAL IN PRESERVING VISION FOR A LIFETIME!

Yes, I choose to have this test performed at this time.

No, I choose to defer this test at this time.

I prefer to discuss this with the Doctor prior to the test.

Signature:______________________________________________ Date:_________________________

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