Download hino Hills Eyecare - Dr. Suneet Gupta, OD

hino Hills Eyecare
Optometry
Dr. Suneet K. Gupta, O.D.
Pupillary Dilation Informed Consent
Dilation of your/ your child’s pupils may be required to perform a comprehensive ocular health and
vision evaluation today. Eye drops are used to enlarge the pupils of the eye. The larger viewing area
allows a three-dimensional inspection of the retina, optic nerve and blood vessels. This leads to easier
diagnosis of eye diseases such as glaucoma, macular degeneration, diabetic retinopathy and cataracts:
all major contributors to adult blindness. Dilating drops also block the eye's natural ability to change
focus during the exam. This eliminates a large variable and allows the doctor to produce a more
accurate prescription. This is essential for most pediatric exams. There is no additional fee for this
procedure when completed on the same day of exam.
Please Note: Your/your child’s vision may become blurry for reading, computer use, and driving. You will
also be light sensitive. These side effects can last from 3 hours all the way to 24 hours. Contact our
office if you feel any adverse reactions occurring that are not listed above.
_____ I DO want to have my/my child’s eyes dilated at this time and understand the side effects.
_____I DO NOT want to have my/my child’s eyes dilated at this time but do understand the importance
of the procedure. (You may ask to schedule another time)
Digital Retinal Imaging Informed Consent
Chino Hills Eyecare is proud to offer state of the art Digital Retinal Imaging. Just as many other
healthcare providers utilize MRI’s, X-rays, or mammograms to aid in diagnosing health conditions; our
office provides a higher level of care with Digital Imaging. The imaging is quick, painless and provides Dr.
Gupta with a detailed image of the inside of the eye (retina).
It can help in early detection of Glaucoma, Cataracts, Macular Degeneration, Retinal Holes/Tears,
Diabetic Retinopathy and signs of Hypertension.
It is also recommended for patients experiencing headaches, floaters and patients with high
prescriptions. Pupil dilation is not necessary for this procedure.
The baseline image remains on file to monitor for changes in the future. Baseline retinal imaging is not
covered by vision or medical insurance. There is a fee of $35.00 for this procedure.
_____I DO want to have a digital retinal image taken.
_____I DO NOT want to have a digital retinal image taken at this time but I do understand the benefits
of the procedure.
Patient Name: ____________________________
Signature:___________________________________Date:_______________________
_______________________________________________________________________________________________________________________________________________
3233 Grand Avenue Suite M, Chino Hills, CA 91709 Ph: (909) 591-2034 FAX: (909) 591-2176