Office Financial Responsibility The Optomap Retinal Scan n produces images that provide the doctor with the widest view to assess the health of your retina. This aids in the detection and prevention of retinal and sub-retinal diseases such as retinal holes, tears, detachments, Macular Degeneration, Diabetic and Hypertensive vascular disease as well as Glaucoma and Optic nerve health. The scan is fast, easy and comfortable. There is an additional fee if $39.00 for this test that is not covered by your insurance. Dr. Gore Strongly recommends the Optomap Scan and imaging for all patients no matter the age. (Required) Yes, I want this imaging done No, I decline Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY PLEASE FILL OUT THE REST OF THE FORMS Please go back to the patient form page and individually fill out the Medical History Form, the Financial Form and the Patient Registration Form.