Digital Retinal Photography Name* First Last Digital Retinal Photography takes a digital view of the back of your eye and puts it into the format of a picture, which is saved onto a computer. This scan can be viewed immediately and examined by the doctor while you follow along. The digital view allows the doctor a much wider field fo view than most traditional retinal exams provide of your retina. Also, because the photo is saved onto a computer, it serves as documentation of the current condition of your eyes, which can aid in the tracking of any changes over the years should anything occur in the future. The doctor strongly recommends that you have this procedure done to allow her to utilize all tools available to assess the health of the eyes, and especially if any of the following apply: DIABETES HIGH BLOOD PRESSURE HIGH CHOLESTEROL CATARACTS FREQUENT OR SEVERE HEADACHES HIGH NEARSIGHTEDNESS SYMPTOMS OF FLASHES OR FLOATERS PERSONAL OR FAMILY HISTORY OF GLAUCOMA OVER THE AGE OF 40 The entire procedure takes less than 5 minutes to complete in most cases. There are no side effects to this procedure as there are with others, such as with dilation causing sensitivity to light and/or blurry vision. There may be a charge of $35.00 for this procedure. A Digital Retinal Photograph should be covered by your health insurance plan for medical eye exams, as long as there is a medical diagnosis deeming it medically necessary and your deductible has been met. This procedure, however, is not covered by your vision insurance. If you have any further questions or concerns, the doctor will be happy to address those with your during the exam.Please check one, and/or sign below and discuss with doctor:*I wish to have the Digital Retinal Photograph doneI do NOT wish to have the Digital Retinal Photograph done todayI wish to have the Digital Retinal Photograph scheduled for another daySignature (Patient or Guardian)*If patient is a minor (under 18 years old), parent must sign this form.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.