Submit Form / Patient Signatures
PLEASE READ THIS ELECTRONIC SIGNATURE CONSENT BEFORE YOU PROCEED. Your electronic signature shall have the same force and effect as an original signature and shall be deemed (i) to be "written" or "in writing" or an âÂÂelectronic recordâ (ii) to have been signed and (iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or "printouts," if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form.
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.
Retinal Examination, Examination and Billing Protocols, Optical Policies - Richmond location only, Patient Owned Frames - Richmond location only, Notice of Privacy Practices, Authorization and Consent
View Retinal Examination, Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent
Please select one of these two options:
I would like
Optomap retinal imaging. I agree to the
$39.00 fee for service. I understand that this new technology is not covered by my insurance.
I prefer dilation with eye drops. I understand that my near vision will be blurry, and my eyes may be light sensitive for up to 6 hours. I understand that I am not supposed to drive more than 3 miles, or operate any machinery until I feel like my vision has suitably recovered.
ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
Date:
Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent Signature
ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
Date: