Optometry Comprehensive Eye Exam Consent

# Optometry Comprehensive Eye Exam Consent > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Practice Name:** ___________ **Doctor of Optometry:** ___________ **License Number:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ --- ## 1. Purpose of the Examination The Patient consents to a comprehensive optometric evaluation, which may include assessment of visual acuity, refraction, binocular vision testing, intraocular pressure measurement, external and internal ocular health evaluation, and any additional procedures the doctor deems clinically indicated. **Chief Complaint / Reason for Visit:** ___________ **Type of Visit:** ___________ --- ## 2. Pupillary Dilation (a) The doctor may recommend dilating the Patient's pupils using topical eye drops (e.g., tropicamide, phenylephrine) to allow complete examination of the retina, optic nerve, and vitreous. (b) **Patient Consent for Dilation:** ___________ (c) The Patient understands that dilation causes temporary blurred near vision and light sensitivity lasting approximately 2–4 hours. The Patient should not drive until vision returns to normal. The Patient may experience a stinging sensation upon drop instillation. (d) In rare cases, dilation drops may trigger angle-closure glaucoma in anatomically predisposed individuals. The office will take reasonable steps to screen for this risk before dilating. ---