Dilation Ultrawide Waiver Auburn Westborough Eye Assc. Ultrawide vs Dilation Waiver And Hippa WaiverTo provide the highest level of care, our doctors strongly recommend that all patients have a thorough examination of their retina. We recommend all new patients have a baseline dilated exam either at the time of their exam or return to the clinic within 6months of their initial exam to be routinely dilated. This appointment will be covered under the first exam. We recommend most individuals age 15+ be dilated every 2 years, and individuals over the age of 40 be dilated every year if indicated. Our office is now pleased to offer the latest in cutting edge technology that provides a 200 degree high resolution image of the retina. We can view up to 90% of the entire retina without the eyes being dilated with the new ultrawide retinal camera. The retinal ultrawide photograph is $39.00 and is NOT covered by insurance for routine eye care. If pathology or a medical diagnosis is documented with this testing, the photographs will be billed to your medical insurance as part of your treatment plan and the $39.00 out-of-pocket charge would be waived. If a medical diagnosis is found, you may be asked to have your eyes dilated either the same day or at a later day and the routine eye exam may become a medical examPlease Check One* Yes, I elect to have the wide field photography done today for $39.00 instead of having my eyes dilated I would like to have my eyes dilated today I would like to come back another day to have my eyes dilated No, I would not like to have my eyes dilated and I do not want to have the wide field retinal photography completed. I understand that a complete retinal exam will not be performed and potential retinal defects may go undetectedWhich Office?*Auburn OfficeWestboro OfficeName (First, Last)*Date* Signature*NOTICE OF PRIVACY ACT, HIPPAI acknowledge that I received or reviewed a copy of Auburn Westboro Eye Associates “NOTICE OF PRIVACY ACT, HIPPA” policy found posted at the office or on the website auburnwestboroeye.comSignature*Date* PhoneThis field is for validation purposes and should be left unchanged.