[et_pb_menu_4 background_layout="primary-menu" menu_layout="inline" _builder_version="3.5" /] Optomap Consent Form Carmel Eyecare is committed to offering our patients the most thorough eye health examination available. The most important part of your eye examination is the evaluation of your eye health which relates to your body’s overall health. Our doctors are trained to look at the earliest signs of conditions like glaucoma, macular degeneration, diabetes, hypertension, cancers and many more. Due to advances in technology, methods used to observe and evaluate your eyes have improved dramatically. Optomap® or widefield digital scanning ophthalmoscopy has become the new standard of care for evaluating the internal parts of the human eye. In most case It is safe, painless and fast It allows for a larger and more magnified retinal view It provides a permanent record for comparing future changes It allows each patient to see and understand their own eye’s internal anatomy Because Optomap® is a diagnostic screening procedure it is not covered by most vision insurance plans. Our office offers this technology to our patients for a low fee of $39. Please select for consent. I choose to utilize Optomap® technology recommended by my eye doctor for my eye health evaluation today for $39.Please select for consent. I choose to decline Optomap® technology today and prefer to undergo dilation of my eyes instead. I understand that dilation of my eye will require an additional 20-25 minutes in my exam and will result in 6-12 hours of blurred eyesight and increased sensitivity to light.Patient or Parent/Guardian Name* First Last Patient or Parent/Guardian Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailThis field is for validation purposes and should be left unchanged. Office Hours Monday 9:00am - 5:00pm Tuesday 9:00am - 5:00pm Wednesday 10:00am - 6:30pm Thursday 9:00am - 5:00pm Friday 8:00am - 3:00pm Saturday Closed Sunday Closed