Myopia Care Program
Atropine Therapy

Atropine Therapy

  • DD slash MM slash YYYY

  • The Program Fee Includes the Following:

    • Eye exam measuring the prescription of the child’s eyes
    • In person visit four times during the course of the 12 months and at least twice a year thereafter
    • Perform the axial length measurement scan at each visit, which assesses how much the myopia has or has not progressed at the retinal level.
    • Conduct training on how to properly instill the drops as to optimize efficacy and minimize wastage.
    • Behavioral questionnaire measurement tool, where we assess how much screen time, outdoor play, study posture has changed over the course of the program.
    • ALL topography, ultrasound and vision testing
    • 24/7 communications necessary between parent/patient and staff/Doctor
    • Behavioral coaching through emails/messages that help parent & patient implement natural behavioral changes needed to support myopia management at home

  • Looking Ahead: Year 2 and beyond: We offer a Myopia Care Maintenance Program which includes:

    • Two follow up appointments
    • ALL topography, ultrasound and vision testing as needed
    • A comprehensive eye exam
    • Any additional training & learning
    • Behavioral coaching messages to support natural changes of behavior in the home

  • The Program Fee Does NOT Include:

    • Supply of Atropine Drops.
  • Initial consultation with the doctor, this service fee is

  • Guarantee:

  • If rare circumstances prevent you from continuing your treatment during the first three months of care, we will gladly refund all fees paid, less

  • Program Requirements:

    • Be on time. Arriving late will create the need for your appointment to be rescheduled.
    • When you need to cancel or reschedule an appointment, inform us at least 48 hours before the appointment. A fee will be imposed if insufficient time is given.
    • Do the homework and preparation that is needed for maximum success for the program including viewing training videos and reading materials.

  • I have read, understand and agree to the terms noted above.

  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY

  • Atropine Drops

    Consent

  • Atropine Drops Therapy

    You are being prescribed Atropine Drops, which help to manage myopia progression.

    Complications and Side Effects

    Atropine drops carry

    I have read and fully understand the above information. I agree to adhere to the schedule and dosage strength of prescribed Atropine Drops and follow-up schedules as prescribed. If I fail to return for my scheduled follow-up visits, I may forfeit my chance to continue Myopia Care program. All of my questions concerning my eyes and atropine drops have been answered to my satisfaction.

  • Reset signature Signature locked. Reset to sign again

  • (Parent to sign if patient is under 18 years of age)

  • Reset signature Signature locked. Reset to sign again
  • MM slash DD slash YYYY