Online Eye Tests Evidence of Problem Form - California Optometric Association
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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.)

Patient Age *
Male/Female *
Diagnosis *

Clear Selection
Please describe in more detail your diagnosis and how it would have been likely missed without a comprehensive eye exam.
(Maximum characters: 2000)
You have characters left.
What risks/symptoms would the patient continue to face if condition was left undetected without a comprehensive eye exam?
(Maximum characters: 2000)
You have characters left.

 

Doctor Information

Doctor's Name (optional)
Optometric License Number *
Doctor Phone Number *



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