Patent Forms

NEW PATIENT WELCOME PACKET

Thank you for joining our family at Southern Retinal Institute. Please download and review our New Patient Welcome Packet.

Download HERE

NEW PATIENT PAPERWORK

Thank you for downloading and filling out this New Patient Paperwork prior to your scheduled appointment. Please print and bring to your appointment. For security reasons, please do not email.

Download HERE

PRIVACY POLICY

This document describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Download HERE

PHYSICIAN REFERRALS

Download our physician referral form HERE

AMSLER GRID SELF-TEST

The Amsler grid, used since 1945, is a grid of horizontal and vertical lines used to monitor a person’s central visual field. The grid was developed by Marc Amsler, a Swiss ophthalmologist. It is a diagnostic tool that aids in the detection of visual disturbances caused by changes in the retina, particularly the macula (e.g. macular degeneration, Epiretinal membrane), as well as the optic nerve and the visual pathway to the brain.1

1https://en.wikipedia.org/wiki/Amsler_grid

Southern Retinal Institute recommends testing your own eyesight weekly by printing out this Amsler grid PDF, provided by the American Macular Degeneration Foundation, and follow the instructions. Please note that the grid does not replace regular comprehensive eye exams.

For further information about the Amsler grid, visit the AMDF at https://www.macular.org/amsler-chart.

Download HERE.