Patient Forms

Please print and complete the following forms before your first appointment. You can print the complete forms package (14 pages) or each form individually.

Complete Forms Package

Patient Forms Package

Individual Forms

Amsler Grid Testing

Amsler Grid Testing is an at-home test to help detect changes in your vision, the Amsler Grid test can be an important indicator of diseases in the retina.

An at-home test to help detect changes in your vision

Instructions For Use

The Amsler Grid test can be an important indicator of diseases in the retina. Test your eyes daily to detect changes as early as possible. If you normally wear reading glasses, please wear them while performing this test. Proper lighting also is essential. The Amsler Grid should be held at normal reading distance and should be tested from the same distance each day.

  1. Look at the dot in the center of the card. Cover one eye and continue to look at the dot for 10 seconds. Do not study it!
  2. If you have retinal disease, the lines surrounding the red dot may not appear perfectly straight.
  3. With a pen or pencil, note any irregularities on the card, such as increased distortion, blurring or blank spots. Indicate the approximate location of the irregularities on the grid.
  4. Repeat the procedure on the other eye.
  5. Notify Retina Consultants of Nevada if you see any sudden or significant changes in your vision.
  6. Please down load the printable version to hang on your refrigerator.
Amsler Grid

Summerlin

653 N. Town Center Drive
Suite 518
Las Vegas, NV 89144

East Side

3006 S. Maryland Parkway
Suite 710
Las Vegas, NV 89109

Green Valley

710 Coronado Center Drive
Suite 201
Henderson, NV 89052

Centennial

6220 N Durango Dr
Las Vegas, NV 89149

Our Satellite Offices

St. George

1791 East 280 North
St. George, UT 84790

Laughlin Office

3650 S. Point Circle, Suite 210
Laughlin, NV 89029

Mesquite Office

1301 Bertha Howe Ave
Mesquite, NV 89027