We provides Comprehensive Eye Examinations, Eyeglasses, and Conventional Contact lenses.

In addition, we provide the following additional services:

Medical care for eye disease
Vision Therapy and Functional Vision Evaluations
Neuro-Optometric Rehabilitation
Specialty Contact Lenses (scleral, color enhancing, prosthetic, etc)
Orthokeratology >
Pediatric and children eye care and vision examinations
Myopia Control

OPTOMAP RETINAL EXAM:

The NEW Daytona Optomap Retinal Examination is prescribed by Dr. Roth to evaluate the health of your retina (back part of the eye). It produces a sharp and wide view of your retina, without using eye drops. The advantages to you are:

Fast (less than 1 second per eye).
No blurred vision afterwards.
You will see the back part of your own eye, and the doctor will explain the findings.
This is now part of your permanent record, so we can then compare the retina from year to year.

This new technology is a part of our standard of care and the fee for this test is $39.00. This test is not covered by any medical insurance.

"I decline the benefits of the optomap retinal exam and hold this office harmless if a medical retinal problem exists but was not identified

Contact Lens Examination:

There are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination.

I have read the terms about the contact lens exam & contact lens assessment.

Patient's Name*

First Last

Brief Questionnaire

1. Are you interested in getting eyeglasses today?

Yes
No

2. Are you interested in getting contact lenses?

Yes
No

3. Is your child having school-related problems or difficulty reading?

Yes
No

4. Are you having vision problems after LASIK or PRK?

Yes
No

5. Are you having vision problems after Brain injury? Crash, fall, etc

Yes
No

6. Are you interested in learning about a Non-Surgical method to correct your vision?

Yes
No

7. Do you wear:

Eyeglasses
Contact Lenses
Both
Neither

8. Do you see clearly at distance, for example, driving or watching TV?

Yes
No
Only if I wear my glasses.
Only if I wear my contact lenses.

9. Do you see clearly at near, for example reading, sewing, computer?

Yes
No
Only if I wear my glasses.
Only if I wear my contact lenses.

10. Do your eyes:

11. Do your eyes feel:

Painful
Achy
Irritated as though there is something in your eyes

12. Do you ever see:

Double
Floaters
Flashes of Light
Sudden Blurred or Reduced Vision

13. Are you bothered by:

Double
Floaters
Flashes of Light
Sudden Blurred or Reduced Vision

14. Occupation - what type of work do you do?

15. At work, do you:

Sit
Stand
Work above eye level
Use computer extensively

16. Hobbies - What types of things do you like to do?

Example: Near work such as reading, crosswords, cards, crafts.

17. What sports are you involved in?

Example: Basketball, Golf, Swimming, Tennis, Racquetball, etc.

Thank you for filling out our welcome form!

You will be redirected to our online patient history form after submitting your answers here. You can also find the link to online patient history form by visiting our contact us page.

Online Patient Registration Form

New Patient Forms (2020)

Step 1 of 3

CHILD EXAMINATION QUESTIONNAIRE FOR PARENTS

School History

GENERAL BEHAVIOR

Signs of Eye Teaming Problems

Signs of Focusing Problems

Signs of Tracking Problems

Signs of Visual Processing Disorders

We provides Comprehensive Eye Examinations, Eyeglasses, and Conventional Contact lenses.

OPTOMAP RETINAL EXAM:

Contact Lens Examination:

Brief Questionnaire

Thank you for filling out our welcome form!

Hours

Dr. S. Moshe Roth, OD FCOVD