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Eye Help for the Public


Online Eye Tests Evidence of Problem Form

Fields marked with * are required.

COA is seeking patient examples to demonstrate to regulators that online eye tests, like Opternative, are potentially harmful to patients. Specifically, we need doctors to write up case examples of patients who met the qualifications for an exam on the Opternative website, but who went to an optometrist instead and were diagnosed with a serious eye condition that would not have been detected by the Opternative website.

Opternative qualifications require patients to be:

1. 18-40 years old.

2. Have a prescription range that is:

  • Emmetropic

  • Myopic with spherical power between "-0.25 and -5.50"

  • Hyperopic with spherical power between "+0.25 and +2.50"

  • Astigmatic with cylinder power between Cyl "-0.25 and -2.50"

  • Non-Presbyopic

3. Have no history of amblyopia, diabetes, hypertension, glaucoma, cataracts, retinal detachment, brain injuries, neurological issues, etc.

4. Have no recent discomfort or symptoms of acute eye pain, flashes and/or floaters in eyes.

If you would prefer to print the form, click here.
After completing the form, please fax to COA at (916) 448-1423.

Patient information

(Please do not include information that can identify the patient.)

First time Rx exceeds range, but patient unaware
Binocular/accommodative error
Ocular health finding
Systemic health finding
Referral to another healthcare provider made
Other (please describe below)
Clear Selection

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Doctor Information

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California Optometric Association
2415 K Street, Sacramento, CA 95816 | 916-441-3990
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