Retinal/Macular Degeneration Screening

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We now have two new highly sophisticated computerized instruments that allow us to provide a more through medical analysis of your eyes. The FORESEE MACULAR ANALYZER is designed to reveal macular degeneration at its onset before damage can cause permanent vision loss. The OPTOMAP SCANNER is a laser driven retinal evaluation system that provides a detailed view of the retina without a dilated pupil. We strongly recommend that all of our patients receive the screening version of these tests. They are especially important for people that have:

1. Headaches
2. See spots or flashes of light
3. A history of diabetes
4. A history of high blood pressure
5. Circulatory problems
6. A strong eye glass prescription
7. Reached age 35
8. A family history of macular degeneration

There is a charge of $50.00 for the Macular Analyzer and $50.00 for the Optomap Retinal Scanner. If you choose both tests the fee is reduced to $90.00. ***These additional tests must be paid in full at the time of your visit.***

Please check the appropriate lines and sign at the bottom

I DO want the Optomap Retinal Screening

I DO want the Macular Degeneration Screening

I DO want BOTH Screenings

I do NOT want the screenings