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 Referral Form
- New Patient Information
- New Patient Medical Information
- Medical Records Release
- HIPAA Notice of Privacy Practices
- HIPAA Notice to Patients
- HIPAA Appointment Designate
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.
- 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!
- If you have retinal disease, the lines surrounding the red dot may not appear perfectly straight.
- 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.
- Repeat the procedure on the other eye.
- Notify Retina Consultants of Nevada if you see any sudden or significant changes in your vision.
- Please down load the printable version to hang on your refrigerator.