Intake Form

Intake Form

Intake Form

Intake Form

Acknowledgement of Notice of Privacy Practices (all patients read and sign): here

Optos and Dilated Fundus Exam Informed Consent


As part of a comprehensive eye examination, Opticore Optometry Group, PC recommends that ALL patients have the internal health of their eyes thoroughly evaluated every year. This can be performed as either a dilated retinal examination or the Optomap retinal imaging. A thorough retinal exam can detect eye diseases including glaucoma, macular degeneration, retinal detachment, and diabetic retinopathy, as well as risk for conditions such as hypertension, diabetes, and stroke. These health conditions are difficult to detect without the Optomap or dilation of the pupils with eye drops due to the limited view of the internal structures of the eye. The Optomap provides an annual, permanent record for your medical file. The ability for our doctors to view last year's image and this year's image side by side for comparison is an invaluable tool in providing comprehensive eye care. Many patients who choose to have the Optomap will not require pupil dilation, however your doctor will determine if dilation is necessary based on your specific conditions or concerns


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Please Check which option today:


  • Optos – 1 minute with no side effects and a digital record saved for year to year comparison : $39 co-pay
  • Dilation – included in your exam with extensive side effects as noted below
  • I refuse both against my doctor’s recommendations : for those declining sign below

I understand that the dilated fundus exam is an important part of my eye exam, because it allows my Doctor to detect disease processes inside my eye - disease processes that can permanently impair my vision. I also recognize that the only way for many of these disease processes to be detected is to have this test performed. Knowing all of this, and that it is in my Doctor's best judgment that this assessment be performed, I hereby decline to have this very important test done and release the Practice, ( Opticore Optometry Group, P.C.) and the doctor from any liability related to the failure to detect and treat any condition in which diagnosis would have been aided by completion of this test.


The Drops that are used to dilate your pupils require about 20 minutes to take effect and will keep your pupils dilated for 2 to 4 hours. The dilation may cause your vision to be temporarily blurry. However, your near vision will improve in 1-2 hours. Also, your eye may be sensitive to sunlight, possibly making driving home and continuing your day's activities somewhat difficult, even with sunglasses. Therefore, if necessary, we can reschedule your dilation for a more convenient time. Side effects from the drops rarely occur, but if you should experience any pain in or around the eyes, hazy vision (halos around lights) or sick feeling, please contact one of the doctors in our offices as soon as possible.

General Practice Acknowledgments.

Sports, Safety, & Children's Glasses: Polycarbonate is the safest material for children and for people involved in sports or activities that present a risk of impact to the eyes or face. This office maintains records for 10 years after the date of the last exam. After that time, the records may be destroyed in a manner that protects patient confidentiality. I understand that I am responsible for payment if my insurance does not cover the services and/or products provided.

Patient Signature


Informed Consent: Finalized Spectacle and Contact Lens Prescription Acknowledgment Form If the doctor deems appropriate, a finalized copy of your glasses, and if applicable, a finalized copy of your contact lens prescription will be provided at the conclusion of the eye exam or Contact Lens fitting.

Sign below to acknowledge that you understand that we will provide copies of your Glasses Prescriptions at the completion of your exam. And if applicable, a Copy of your Contact Lens Prescription at the completion of your contact lens fitting.

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