Visual Field/Photos/Dilation Consent Form VISUAL FIELDA critical part of comprehensive eye care is a visual field. We highly recommend this test which gives a computerized examination of your side (peripheral) vision. Many diseases revealed by a visual field are undetectable in an eye examination and may only be diagnosed with a visual field. Some of the diseases that a visual field may detect are GLAUCOMA, RETINAL DISEASE, BRAIN TUMORS, and many other disorders relating to the eye and brain. The fee for this test is $10.00. Most insurance will cover this cost. (If you are a Veteran, this is normally covered by the VA through the Choice Program.) Yes, I give consent to have a visual field. No, I decline to have a visual field performed. I understand that this test helps in the detection of many diseases which can cause permanent and irreversible vision loss. I also decline this important part of my eye examination and release all doctors, personnel, and businesses associated with this facility from any liability related to the failure to detect and treat any condition in which the diagnosis would have been aided by this test. OPTOS PHOTOS (Pictures of your retina: nearly all of the back of your eyes)A possible alternative to dilation is the OPTOS. This machine takes a picture of the back of your eye and can, in many instances, be better than dilation. This machine takes a picture of almost the entire backside of your eyes and has proven to be better at spotting problems than dilation. Some diseases and problems that this machine may detect better than dilation are: MACULAR DEGENERATION, DIABETIC RETINOPATHY, RETINAL DETACHMENTS, GLAUCOMA...just to name a few. Yes, I consent to OPTOS photos. (FREE for 1st visit and $10 for each additional visit.) Do not mark yes for the OPTOS if you have any history of epilepsy. No, I do not consent to OPTOS photos. I understand that this test helps in the detection of many diseases which can cause permanent and irreversible vision loss. I also decline this important part of my eye examination and release all doctors, personnel, and businesses associated with this facility from any liability related to the failure to detect and treat any condition in which the diagnosis would have been aided by this test. DILATION No,I decline to have my eyes dilated, UNLESS IT IS NECESSARY. I understand this is an important part of my eye examination and release all doctors, personnel, and businesses associated with this facility from any liability related to the failure to detect and treat any condition in which the diagnosis would have been aided by this test. Yes, I give consent to have my eyes dilated. We do not guarantee what you can or cannot do (INCLUDING DRIVING) while dilated. So please do not ask if you can drive because everyone is affected differently. There are two main effects from pupil dilation. The first effect for about 2 hours is decreased distance and near vision and the second effect is increased sensitivity to light for about 6 hours. Patient/Legal Guardian SignatureDate MM slash DD slash YYYY Please take a moment and tell us how you heard about us: Referred by a doctor VA Internet Phone Book Radio Walmart HWY sign Theatre ad Other Of other, please specify: If friend/family referred you: Please tell us who you so we can thank them
