New Member Form

DILATED RETINAL EXAM

Dilated eye exam is recommended to thoroughly evaluate your ocular health. Dilation drops enlarge the pupils to enhance the detection of ocular diseases. There is no additional fee for this exam. A $25 fee is applied if you choose to schedule a second appointment for dilation. Possible side effects include: inability to focus at near, sensitivity to light, blurred distance vision for some patients, mild burning upon instillation and in RARE cases induced ocular hypertension in which redness and sharp pain is experienced because of increased eye pressure. If this happens, contact the doctor immediately.

I understand the above and consent to have dilationI understand the above and decline dilation at this time. I understand the potential for ocular diseases and loss of vision may exist, and without dilation, may go undetected.

ASSIGNMENT OF BENEIFTS AND FINANCIAL RESPONSIBILITY

I authorize the release of any medical information necessary to process this claim and request payment of medical benefits to be made directly to Stratford Eye Care Optometry, unless payment is made in full at time of service. I agree to bear full responsibility for co-pays, deductibles, non-covered and denied services by my insurance.