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2023-02-02T00:32:04+09:00
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I DO want the procedure performed.
I DO want the procedure performed.
I DO NOT want the procedure performed.
I DO NOT want the procedure performed.
Signature Date
Signature Date
At Lowcountry Eye Care we pride ourselves on providing our pati
At Lowcountry Eye Care we pride ourselves on providing our patients with the best possible standard of care. Because of this, we now perform the optomap Retinal Exam with all of our patients. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Your Doctor strongly believes that the optomap Retinal Exam is an essential part of your comprehensive eye exam and prescribes it for all patients once per year. As part of your pre-test work up, we will capture optomap images for review with your Doctor during your examination today. The $35 co-pay for this procedure is a non-covered service unless being used to actively follow disease.
I DO want the procedure performed.
I DO want the procedure performed.
I DO NOT want the procedure performed.
I DO NOT want the procedure performed.
Signature Date
Signature Date
At Lowcountry Eye Care we pride ourselves on providing our pati
At Lowcountry Eye Care we pride ourselves on providing our patients with the best possible standard of care. Because of this, we now perform the optomap Retinal Exam with all of our patients. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Your Doctor strongly believes that the optomap Retinal Exam is an essential part of your comprehensive eye exam and prescribes it for all patients once per year. As part of your pre-test work up, we will capture optomap images for review with your Doctor during your examination today. The $35 co-pay for this procedure is a non-covered service unless being used to actively follow disease.
I DO want the procedure performed.
I DO want the procedure performed.
I DO NOT want the procedure performed.
I DO NOT want the procedure performed.
Signature Date
Signature Date
At Lowcountry Eye Care we pride ourselves on providing our pati
At Lowcountry Eye Care we pride ourselves on providing our patients with the best possible standard of care. Because of this, we now perform the optomap Retinal Exam with all of our patients. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Your Doctor strongly believes that the optomap Retinal Exam is an essential part of your comprehensive eye exam and prescribes it for all patients once per year. As part of your pre-test work up, we will capture optomap images for review with your Doctor during your examination today. The $35 co-pay for this procedure is a non-covered service unless being used to actively follow disease.
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