EyeCare One
Dr. Kenneth Crawford
7793 Joan Drive
West Chester, OH 45069
(513)755-7775
Dilation Consent Form
Dilation exam is a procedure in which drops are instilled in
each eye to increase the pupil size so that the inside of your eye
may be inspected better by the doctor. This procedure has
been recommended by the doctor so that he can provide you
with the most thorough eye health examination possible.
CHECK THE STATEMENT WHICH APPLIES AND SIGN
I do want to have this procedure performed and
understand the importance of a Dilation exam.
J do not want to have this procedure performed and
understand the importance of a Dilation exam.
Patient Signature
Date_