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Burnt Hills Optical

A visual field examination determines to what degree you are able to see peripheral objects while fixated on a

stationary object. It electronically measures retinal function. This measurement can assist in the early detection of

many disorders; including glaucoma, brain tumors, diabetic retinopathy, retinal detachments, hypertensive retinopathy,

and many other conditions which can manifest itself in the eye.

Using the Visual Field Instrument, we are now able to provide a more thorough medical analysis of your eyes,

not able to be provided through a routine eye examination. Our Humphrey FDT electronically measures retinal function

and sensitivity to light, to aid in the diagnosis of those very serious diseases. There is currently no better method of

early detection and therefore early treatment.

We strongly recommend that all our patients receive the screening version of this test. It is especially important

for people who:

• Experience frequent headaches

• Have a history of glaucoma

• Are a stroke candidate and/or had a stroke

• See spots or flashes of light

• Have a history of diabetes

• Have a history of high blood pressure

• Require a strong eyeglass prescription

• Require frequent change in their prescription

• Are 35 years of age or older

There is an additional charge of $10 for the screening exam. You will be given a receipt for submission to your

insurance company.

Please check the appropriate line below and sign at the bottom.

_____ I DO want the Visual Field Exam

_____ I DO NOT want the Visual Field Exam

Patient Signature_________________________________________ Date_____________

Burnt Hills Optical Page 3