Skip to main content
Sandusky
419-757-8950
Home » Returning Patient Registration

Returning Patient Registration

  • Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

    This form contains confidential information and is delivered to your doctor through a secure Internet connection.

  • Patient Information

  • If you had an address change, please provide us with your up to date information:
  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide us your email address.
  • Eye History

  • Medical History

  • Vision Insurance

  • If you do not see your insurance on the list below, please call us to see if we are a provider.
  • Medical Insurance

  • In some cases, medical insurance has to be billed for your eye exam. Vision insurance is for “routine” eye examinations. Medical insurance is for situations where there is an indication of a medical symptom.
  • If you have coverage through another plan/organization, please fill in the details below.
  • MM slash DD slash YYYY
  • Please bring all insurance cards with you to your appointment.
  • Optomap vs. Dilation

  • The Optomap Retinal Exam, an ultra-widefield retinal examination, is a revolutionary diagnostic tool that allows clinicians to view a majority of the retina. The Optomap Retinal Exam is a non-dilating camera that captures a digital image of the retina. The Optomap allows the doctor to capture a 200° high-resolution image of the retina in a single shot-- without dilation -- in a quarter of a second. It is easy for the patient, takes just a few minutes to perform, and is immediately available for review with the patient in the exam room.

    Dilation, the traditional method, requires eye drops that enlarge the pupil area and blurs vision for approximately 4 to 6 hours. The drops require 30 minutes to take affect and then another 10 to 15 minutes of evaluation with a bright light source and a magnifying lens. The resulting clinical evaluation is like the Optomap, if the clinician is experienced, patient is cooperative and pupil dilation is maximized. A comprehensive dilation is achieved through 8 to 10 individual inverted views of each retina that is documented on the exam form.

    Dr Zimmerman and Dr Uzl recommend the Optomap retinal screening because:
    • It allows for an enlarged image to see a more detailed view of the retina
    • It takes just a few minutes start-to-finish, rather than approximately 45 minutes with dilation
    • You leave the office with vision intact, rather than with light-sensitivity and blur
    • Creates a permanent record
    • Allows for future comparisons--we can compare this year’s image to next year’s image—side by side
    • Can be reviewed by other doctors, if necessary
  • Comments

  • Privacy Policy

  • This field is for validation purposes and should be left unchanged.