ProSites, Inc.
1590675-819150Printed Name of Patient: ___________________________Date: __________________CONSENT FOR CARE AND TREATMENTThis consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended: and (2) you consent to treatment at this office or any office under common ownership. The consent will remain fully effective until revoked in writing. You have the right at any time to discontinue services.________________________SignatureCONSENT TO DILATE EYESDilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time which varies from person to person and make bright lights bothersome. Because driving may be difficult immediately after your exam, it is best if you have someone with you to drive you home. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.I hereby authorize the doctor and/or assistants as may be designated by him/her to administer dilating eye drops at any/all visits. The eye drops are necessary to diagnose my condition.________________________SignatureREFRACTIONA Refraction is a measurement that determines the best potential vision for your eyes. A Refraction is done by a technician so your physician can determine your vision for glasses, contacts or for determining and evaluating your eye health. This is particularly helpful when patients have multiple issues affecting their eyes such as cataract, glaucoma and macular degeneration. Despite being medically necessary refractions are not considered a covered procedure by most insurance plans including Medicare. The charge for this service is $50.00 and payable upon checking out after your visit.I have read and understand the above regarding refractions and understand that I am financially responsible for the charges not covered by my insurance company and guarantee payment at the time of my visit.________________________SignatureCONTACT LENS FEES (new or current wearers)This exam is critical to assure the good health of your eyes for all contact lens wearers; as well as determining an accurate current prescription. The contact lens fitting is not part of a complete eye exam, but is an additional service. Contact lens fees range from approximately $35 - $120. Please refer to the contact lens fee table located in each office.______________________Signature ................
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