Retinal Exam Experience the Convenience of the Optomap Retinal Exam The Optos California provides an unequaled 200 degree view of your retina in a high-resolution, highcontrast digital image- the Optomap. This comprehensive view of up to 82% of the retina (in oneimage) gives our doctors the opportunity to identify and follow peripheral retinal pathology much moreeasily. The optomap® Retinal Exam is fast, easy, and comfortable. We can now avoid the strongdilating drops during the exam and travel home without the worry of being dilated or requiringsomeone to drive you. In order to provide the highest level of care, we are now incorporating the latest technology to detect eye as well as systemic diseases in the earliest stages. Dr. Donlon and Dr. Bubnovsky both strongly recommend that all of our patients have this procedure performed annually. This scan aids our doctors in early detection of the pathology below. If you feel any of these apply to you or any family members please feel free to answer Yes or No below: Brain Tumors / Melanoma Cancer of the Eye Headaches Retinoschisis Hypertenstion Complications of lupus Breast Cancer / Family History Lung Cancer / Family history Macular Degeneration Choroidal Nevus Flashes and Floaters Diabetes Retinal Detachments Complications of MS Sickle Cell Trait Thyroid disease Glaucoma High cholesterol AIDS Retinal holes Complications of RA The fee for this procedure is $39. Please answer yes or no on the appropriate line and print and signthe bottom. For more information or to view an informational video visit www.optomap.com or ask toview a demonstration. I DO want the scan done today I would like to discuss with Dr. Donlon / Dr. Bubnovsky I would like to see a demonstrational video Name First Last SignatureDate MM slash DD slash YYYY