Testing Procedures Informed Consent/Refusal Because our office is committed to providing the best possible care to our patients, your doctor strongly recommends three additional tests that aid in the early detection of several different eye diseases. Your doctor may require these tests when they are indicated by examination. PUPILLARY DILATIONThis is the use of eye drops that act to temporarily enlarge the pupil which allows the doctor to more thoroughly evaluate the internal structures of your eyes. Without pupillary dilation, certain eye and general health diseases can go undetected. This procedure is especially recommended for patients who are highly nearsighted, diabetic, or hypertensive. The effects of pupillary dilation include temporary blurring of near vision and temporary light sensitivity. Distance vision is generally not affected although you can reschedule and choose to have someone drive you. The fee for pupillary dilation is an additional $15.00.I understand the risks and benefits of pupillary dilation and:*I want my eyes dilated.I want to return at a later date to have my eyes dilated.I do not want my eyes dilated.VISUAL FIELD SCREENINGVirtually all of the major causes of blindness can be detected by changes in the visual field. This short, painless computerized test checks for areas of subtle loss of sight both in the central and peripheral areas. It can assist in early detection of glaucoma, retinal problems, some neurological diseases including brain tumors and optic nerve disease. It can also enable the doctor to better diagnose causes of headaches. The test does not affect your vision. The fee for this service is an additional $20.00.I understand the risks and benefits of visual field screening and the risks of not having it performed and:*I want the visual field screening.I do not want the visual field screening.RETINAL PHOTOGRAPHYThis is the use of a computerized camera that produces a color photo of the inside of the eye. This test improves the quality of your examination by providing a permanent visual record of the internal structures of your eyes. This short, painless test will not affect your vision. The fee for this service is $20.00.I understand the risks and benefits of digital retinal imaging and:*I want retinal photography.I do not want retinal photography.Patient/Guardian Signature*Date* Date Format: MM slash DD slash YYYY
