Los Gatos Eye Care

15563 Union Ave.
Los Gatos, CA 95032

(408) 377-2020
fax: (408) 377-2022

Welcome Forms

Below are our patient forms. You may choose to print and fill them out prior to your initial appointment. You will need Adobe Acrobat Reader to view these files:

Download Acrobat Reader

optomap Retinal Exam Click here for an optomap informational video

optomap® Retinal Exam

Annual eye exams are vital to maintaining your vision and overall health. Los Gatos Eyecare offers the optomap® Retinal Exam as an important part of our eye exams. The optomap® Retinal Exam produces an image that is as unique as you fingerprint and provides Dr. Polhemus and Dr. Mohtadi with a wide view to look at the health of your retina. The retina is the part of your eye that captures the image of what you are looking at, similar to film in a camera.  

Many eye problems can develop without you knowing. You may not even notice any change in your sight.  But, diseases such as macular degeneration, glaucoma, retinal tears or detachments, and other health problems such as diabetes and high blood pressure can be seen with a thorough exam of the retina. 

An optomap® Retinal Exam provides:

  1. A scan to show a healthy eye or detect disease.
  2. A view of the retina, giving your doctor a more detailed view than he/she can get by other means.
  3. The opportunity for you to view and discuss the optomap® image of your eye with your doctor at the time of your exam.
  4. A permanent record for your file, which allows [Doctor Name(s)] to view your images each year to look for changes.  

The optomap® Retinal Exam is fast, easy, and comfortable for all ages.  To have the exam, you simply look into the device one eye at a time and you will see a comfortable flash of light to let you know the image of your retina has been taken. The optomap® image is shown immediately on a computer screen so we can review it with you.

Please schedule your optomap® Retinal Exam today!

 For more information on the optomap® Retinal Exam, go to the Optos website at www.optos.com



Vision Service Plan Patients

   Consent Form
   Notice of Privacy Practices
   Patient History
   Acknowledgment Form
   Signature on File



Private-Pay Patients

   Notice of Privacy Practices
   Patient History
   Acknowledgment Form

   Signature on File



InfantSEE Forms

   English
   Spanish



Los Gatos Eyecare is happy to offer a "Dog-friendly" office. Click here to see some of our canine guests.