Office phone numbers: North (317) 844-6269
Earl E. Lanter MD
South (317) 887-7777
James E. Wilson OD, FAAO
Castleton (317) 598-2020
Donald H. Hulsey OD
Fax (317) 815-7567
After Hours (317) 631-3466
Allison L. Nowak OD, FAAO
Routine eye examinations do not detect all diseases in their early stages. However, modern technological advances
have made it possible to spot subtle vision problems that may be indicative of the beginning states of eye disease.
One such device is the Frequency Doubling Technology Visual Field Tester (FDT). This sensitive instrument can
detect such diseases as pituitary tumors, glaucoma, retinal and macular degeneration, optic nerve disease and
retinal disturbances due to vascular problems or medications, even though you may not have noticed any change
in your vision.
We recommend that all patients over the age of 18 receive this test. It may be especially important in those patients
who have a history of high blood pressure, diabetes, headaches, migraines, floaters, a high spectacle
prescription, retinal problems, or a family history of eye problems.
Because this is a screening test, FDT is NOT covered by your insurance. There is a nominal fee of $30.00 for this
test, payment of which is your responsibility. This fee is due at the conclusion of your examination today.
Please check the appropriate box and sign below:

I would like a comprehensive eye examination (including the FDT test) today.

I understand the importance of the FDT screening and understand this test is in my best interest, but I prefer
the general eye examination only. (Exam does NOT include the FDT test.)
Signed: _____________________________________________ Date: _______________
Printed name: ________________________________________________
REVISED 09 2007 FORM #031