Retina Health Informed Consent

Retina Health Informed Consent

Retina Health Informed Consent

Retina Health Informed Consent


Dr. Bonomolo uses today’s most advanced technologies to provide the most thorough eye health evaluations possible. Two of these technologies are available at Optic Owl Co, the (OCT) OPTICAL COHERENCE TOMOGRAPHY (OCT), Retinal / Fundus Imaging, and Visual Fields (HVF). The OPTICAL COHERENCE TOMOGRAPHY (OCT) is a non-invasive imaging test that uses light waves to take cross-section pictures of your retina, the light-sensitive tissue lining the back of the eye. It provides very detailed digital images of your Optic Nerve, Macula and Retina in both 2D and 3D views. Both tests will allow us to detect certain eye health problems at the earliest stages, often years before a patient would be aware something was wrong with their vision. Detecting potentially blinding diseases in the earliest possible stages always provides the best chance for preventing permanent vision loss. With these tests we will be able to more accurately and efficiently evaluate you for all eye diseases, cancers and other deteriorating eye health issues. We strongly recommend all patients have the images taken at each year’s exam.

The OCT may be covered by most major health insurance plans if we detect one of the above conditions. If we are unable to bill your insurance for the HVF, OCT, or Images, the fees are listed below at an out of pocket discount for the patient's benefit.
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By choosing Fundus & OCT the dilation drops/process can be avoided at your visit. (Unless medically necessary)

Most insurance companies require us to do one or the other. Dilation can last anywhere from 3-4 hours up to 24 hours depending on the patient and the drops needed. Please ask all questions you may have before signing.


If there is medical diagnosis, medications taken to control medical diagnosis for a patient there WILL BE photos taken & medical ins. will be billed.

​​​​​​​Please choose Y for yes or N for no by which test or tests you would/would not like to receive at today's visit.


Fundus & OCT: $40

(Visual Fields) HVF: $50

*If we are filing your insurance then you MUST be EITHER dilated OR have images taken at each visit, NO exceptions will be made.


*Signature of Understanding: I have read the above stated financial policy, I accept the responsibility for services as outlined above.
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