Optomap & Dilation Waiver

Phone: <a class="ecp-phone-call-phone" href="tel:(512) 458-3348" style="text-decoration:none"> (512) 458-3348
Text: <a class="ecp-phone-call-sms" href="sms:(512) 458-3348" style="text-decoration:none"> (512) 458-3348
Fax: (512) 458 4018
Email: visionsourceaustin@gmail.com (Do not send personal health information by email.)

I understand that I can have my retinas examined either by the Optomap procedure or by having my eyes dilated. By foregoing both the Optomap and dilation procedures. I will not hold Vision Source Austin or Dr. Davis responsible for my retinal and eye health.

I understand and agree
- Yes
- No
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