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Home » Diabetic Exam Form

Diabetic Exam Form

Patient Name
MM slash DD slash YYYY

Primary Care Physician

Taking Insulin?
Do you self monitor every morning?
I would like to receive an updated prescription for glasses during my visit for $45

You Should Know!

Please be advised that as part of your diabetic eye exam, your pupils will need to be dilated for a thorough evaluation of your eye health. This procedure is a standard part of this type of examination and is necessary for the detection of potential vision-threatening conditions. Additionally, this visit will be billed to your medical insurance and not your vision plan. Thank you for your understanding.