We are committed to providing quality eyecare to our patients by using the most advanced equipment and techniques. The following tests can often identify changes at early stages before they become significant problems. We strongly recommend that our patients receive the following tests as part of their comprehensive eye examination.

In order to more thoroughly examine the inside of the eye for diseases such as glaucoma, cataracts, tumors, and retinal degenerations it is best to dilate (enlarge) your pupils. After the initial examination, 2-3 drops will be instilled in each eye. It then takes an additional 20-30 minutes for your pupils to dilate. Your pupils will gradually return to their normal size over a period of 4-6 hours. During that time you will be sensitive to bright lights and reading and other close work, including computer work, will be difficult. We will provide free, disposable sun shields if needed for light sensitivity. Most people are comfortable driving, however, if you do not feel comfortable with your vision after dilation, please call someone to pick you up or bring someone to drive you home. If dilation should be contraindicated in your case, the doctor will inform you. We realize that not every patient’s schedule will allow him or her to undergo this procedure. However, we feel that the benefits outweigh the disadvantages and recommend that our patients have their eyes dilated when possible. You may return to have your eyes dilated at a later date if you choose. There will be no additional charge as long as you do so within 30 days of today’s examination date. There may be some instances in which we may not be able to dilate your eyes the same day as your examination due to scheduling, an emergency, or other unforeseen circumstances.

Most major causes of blindness in the United States can often be detected by changes in the visual field. A highly sophisticated computerized instrument now enables us to provide a visual field screening in less time and at much less cost. This instrument checks for areas of reduced vision in the central (straight-ahead) and peripheral (side vision) areas. Visual field testing is important in the early diagnosis of glaucoma, retinal problems, and some neurological diseases such as brain tumors and optic nerve disease. Unfortunately, an individual does not notice most visual field defects until very late stages. Early detection significantly increases the chances of either curing the disorder or at least minimizing its effects. There is an additional fee of $10.00 for the visual field screening.

Liability Release: I have been informed by the office of Kevin Gajda, O.D. and his associate optometrists of the importance of pupil dilation and visual field screening. I have chosen not to have one or both of these tests performed, and I will not hold the office of Kevin Gajda, O.D., his associates, and/or his staff responsible for any disease or pathology (or its effects) that goes undetected due to the lack of diagnostic information that could have been obtained by these testing procedures.

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review the practice’s Notice of Privacy Practices (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain any revised notices at the practice. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restrictions, they must follow the restriction(s). I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.