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Eyefinity Online Appointment Scheduler: Digital Retinal Imaging Acknowledgement Form

Go paperless with the Digital Retinal Imaging Acknowledgment form in your Eyefinity® Practice Management Online Scheduler. Customize your digital form and administration settings.

All fields are required unless noted.

Practice Information

Form Content

Verify the questions you’d like to include in your Digital Retinal Imaging Acknowledgement form. You can use the suggested default questions or edit to customize.

Please see the example of what the form will look like when published to your website using the default text.

Form Title
This title is shown on initial "Forms to Fill Out" page.
Header
Description
Image Selection
Please select the image you'd like to include on the form.
Button Text
Text to view PDF with more information about Retinal Imaging.
Can you provide a link to the PDF?

Please ensure your PDF size does not exceed 2MB.

Provide your email address to receive instructions on how to submit the PDF. Please only send forms by replying to the email with instructions and ensure your PDF size does not exceed 2MB. Any email sent with an attachment that exceeds the file size and has no-account info or case number will not be processed.

Acknowledgment Statement
Text providing more information to the patient, including the cost.
Acknowledgment Label 1
Acknowledgment Label 2
Above Signature Label
Help Text in the Signature Field
Below Signature Text

Form Administration

Customize administration settings to align with your practice workflow.

Select the form expiration time, which is the number of days before the patient is required to complete the form again. For example, if you want the patient to complete the form once a year, select 365 days.

Which locations will use this form?
When the form is uploaded to the patient’s record in EPM, what name do you want to display on the Patient Correspondence – Documents Page?

Attestation

Please complete this attestation before submitting the form.