I, First Name* Last Name* have been informed on this date by my optometrist of the need for a dilated examination of my eyes. It has been explained to me and I understand that a condition with the potential for partial or total loss of vision may exist and without dilation it may go undetected.Being advised of the above, I hereby decline to have my eyes dilated.
I, First Name* Last Name* have been informed on this date by my optometrist of the need for an eye pressure test to screen for glaucoma. I have been informed and understand that if I have glaucoma and a pressure test is not performed, the disease may be undetected with the potential for a partial or total loss of vision. I have also been informed of the various means by which my eye pressure may be tested. Being advised of the above, I hereby decline an eye pressure test.