Consent Forms
Welcome to OMIC’s Consent Form library, a collection of procedure-specific consent forms that you can modify to suit your practice and patient population. Contact riskmanagement@omic.com with questions.
Found
65
resources.
Jul 1, 2015
| Consent Form
...that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 07/01/2015 There are four parts to the plain-language cataract consent forms: · Use the main cataract consent form for all patients having cataract surgery www.omic.com/cataract-plain-language-consent-forms/ · Add an addendum if needed: · Astigmatism correction:...
Aug 25, 2024
| Consent Form
...the cataract. HOW WILL REMOVING THE CATARACT AFFECT MY VISION? The goal of cataract surgery is to correct the decreased vision that was caused by the cataract. During the surgery, the ophthalmologist (eye surgeon) removes the cataract and may place in a new artificial lens called an intraocular lens or...
Nov 7, 2019
| Consent Form
...ghost-like images. A cataract will get worse if not removed. Surgery is the only way to do so. It is your choice when to have cataract surgery. Most people wait until their vision problems interfere with daily life. You can instead decide not to have your cataract removed. During cataract...
Sep 24, 2014
| Consent Form
...removed. Surgery is the only way to remove a cataract. You can decide not to have the cataract removed. If you don’t have the surgery, your vision loss from the cataract will continue to get worse. HOW WILL REMOVING THE CATARACT AFFECT MY VISION? The goal of cataract surgery is...
Aug 27, 2024
| Consent Form
...CENTER AS VERIFICATION THAT YOU HAVE OBTAINED INFORMED CONSENT. KEEP THE ORIGINAL IN THE PATIENT’S MEDICAL RECORD. There are four parts to the plain language cataract consent forms: Use the main cataract consent form for all patients having cataract surgery www.omic.com/cataract-plain-language-consent-forms/ · Add an addendum if needed: · Astigmatism correction:...
Aug 27, 2024
| Consent Form
...informed consent. Keep the original in the patient’s medical record. Version 07/01/2015 ) There are four parts to the plain-language cataract consent forms: · Use the main cataract consent form for all patients having cataract surgery www.omic.com/cataract-plain-language-consent-forms/ · Add an addendum if needed: · Astigmatism correction: use for toric IOL...
Jul 16, 2014
| Consent Form
[bookmark: _GoBack]Add your letterhead to the first page of the consent form Change font size for large print. 1/7/19 IMMEDIATE SEQUENTIAL BILATERAL CATARACT SURGERY My ophthalmologist (eye physician and surgeon) has determined that I have cataracts in both eyes. I would like to have the surgery done on both eyes...
May 10, 2023
| Consent Form
...cataract affect my vision? The goal of cataract surgery is to correct the decreased vision that was caused by the cataract. During the surgery, the ophthalmologist (eye surgeon) removes the cataract and puts in a new artificial lens called an intraocular lens or IOL. Cataract surgery will not correct other...
Oct 9, 2014
| Consent Form
...reading or, for all of these activities. · With increasing age, patients are likely to develop cataracts. If the cataracts are significant enough to cause visual problems, the phakic implant may need to be removed so that the eye can undergo cataract removal with or without implantation of a suitable...
Feb 13, 2020
| Consent Form
...for another surgery · Worse or lost vision · Pressure that is too low · Damage to the eyeball · Infection · Bleeding in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as...
Feb 12, 2020
| Consent Form
...eye, with the need for another surgery · Worse or lost vision · Pressure that is too low · Damage to the eyeball · Infection · Bleeding in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at...
Apr 16, 2012
| Consent Form
...there is no cataract. In some cases, the lens may have an early cataract which does not significantly interfere with corrected vision, and which would normally not require surgical removal. The eye surgeon, known as an ophthalmologist, surgically removes the natural lens of the eye and replaces it with an...
Mar 5, 2021
| Consent Form
...is recommending Laser Capsulotomy after Cataract surgery. What is YAG Laser Capsulotomy? YAG Capsulotomy is a laser treatment used to improve vision after cataract surgery, and is usually performed as an outpatient. A common occurrence after cataract surgery is clouding of the part of the natural lens covering (the capsule)...
Dec 9, 2020
| Consent Form
...blood flow to parts of the eye Retinal detachment with the need for another surgery to repair it Cataract, or clouding of the lens in your eye. You may need surgery to remove the cataract if it interferes with your vision. Elevated eye pressure (glaucoma) Damage to the cornea, the...
Feb 13, 2020
| Consent Form
...· Infection, soon after surgery or years later · Bleeding in the eye · Inflammation · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort...
Feb 13, 2020
| Consent Form
...Damage to the eyeball · Bleeding in the eye · Infection · Inflammation · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma procedure) · Pain, irritation, or discomfort in the...
Feb 13, 2020
| Consent Form
...years later · Bleeding in the eye · Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as the glaucoma surgery) ·...
Feb 13, 2020
| Consent Form
...months or years later · Bleeding in the eye · Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as the glaucoma...
Feb 13, 2020
| Consent Form
...for another surgery · Worse or lost vision · Pressure that is too low · Damage to the eyeball · Infection · Bleeding in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as...
Feb 13, 2020
| Consent Form
...· Worse or lost vision · Pressure that is too low · Damage to the eyeball · Infection, soon after surgery or months or years later · Bleeding in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery...
Feb 13, 2020
| Consent Form
...Damage to the eyeball · Infection, soon after surgery or months or years later · Bleeding in the eye · Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are...
Feb 13, 2020
| Consent Form
...too low · Damage to the eyeball · Infection · Bleeding in the eye · Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma...
Feb 13, 2020
| Consent Form
...in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort in the eye or surrounding tissues that may last · Drooping of eyelid · Double...
Feb 13, 2020
| Consent Form
...Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort in the eye or surrounding tissues that may persist · Drooping of eyelid · Double vision · Problems during surgery that...
Feb 13, 2020
| Consent Form
...later · Inflammation · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Droopy eyelid · Pain, irritation, or discomfort in the eye or surrounding tissues that may lasts...
Feb 12, 2020
| Consent Form
...· Bleeding in the eye · Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort...
Feb 13, 2020
| Consent Form
...Inflammation · Mechanical problem with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort in the eye or surrounding tissue...
Feb 21, 2020
| Consent Form
...the eyeball · Infection · Bleeding in the eye · Inflammation · Cataract (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort in the eye or surrounding tissues that may last...
Dec 9, 2020
| Consent Form
...serious risks: Retinal detachment with the need for another surgery to repair it Elevated eye pressure (glaucoma) Damage to the cornea, the clear covering of your eye that may not heal well. This damage may cause scarring or clouding, which causes poor vision. Cataract, or clouding of the lens in...
Mar 13, 2020
| Consent Form
...implant. While your eye surgeon cannot tell you about every risk, here are some of the most common or serious ones: · Risks from steroids · Cataract (clouding of the eye’s lens) leading to the need for cataract surgery · High eye pressure, leading to optic nerve damage and glaucoma,...
Feb 13, 2020
| Consent Form
...with an implant requiring removal or repositioning · Cataract or clouding of the lens (except if you have already had cataract surgery or if you are having cataract surgery at the same time as this glaucoma surgery) · Pain, irritation, or discomfort in the eye or surrounding tissues that may...
Mar 13, 2020
| Consent Form
...YUTIQ contains a steroid. While your ophthalmologist cannot tell you about every risk, here are some of the most common and serious ones: · Risks from steroids · Cataract (clouding of the eye’s lens) leading to the need for cataract surgery · High eye pressure, leading to optic nerve damage...
Dec 7, 2012
| Consent Form
...Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s lens) · Glaucoma (increased eye pressure) · Hypotony (reduced eye pressure) · Retina or cornea damage · Bleeding within the eye · Inflammation inside the eye that can cause...
Nov 21, 2014
| Consent Form
...melt with perforation, scarring of the conjunctiva or cornea, iritis, glaucoma, cataracts, and possible need for further surgery. *FDA status of MMC in Eye surgery MMC was approved by the Food and Drug Administration (FDA) for the treatment of various types of cancer. Upon approval, the drug manufacturer produces a...
Oct 8, 2014
| Consent Form
...permanent. · Infection, which if severe could result in the loss of the eye · Corneal edema · Corneal perforation, which could lead to infection, or, rarely, a cataract · Decrease in best-corrected visual acuity · Other procedures may be required to reach the desired result. While there is no...
Dec 8, 2020
| Consent Form
...increase the time it takes for you to stop bleeding. Patients who are having cataract surgery can usually keep taking these medications. Patients who are having eyelid, orbit, or retina surgery usually need to stop the medications before the surgery. Bleeding is a potential complication of any surgical procedure. People...
Mar 13, 2020
| Consent Form
...vision may get worse. · Lucentis injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s lens) · Glaucoma (increased eye pressure) · Hypotony (reduced eye...
Jan 7, 2020
| Consent Form
...damage to the corneal transplant. Usually, eye drops can stop rejection. · Ophthalmologists often can do PK surgery at the same time as cataract or glaucoma surgery. This means that patients with those other eye problems might need just one surgery. Disadvantages of PK corneal transplant surgery include: · PK...
Aug 4, 2020
| Consent Form
...infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s lens) · Glaucoma (increased eye pressure) · Hypotony (reduced eye pressure) · Retina or cornea damage · Bleeding within the eye · Inflammation inside the eye that...
Mar 19, 2023
| Consent Form
...inside the eye that can cause vision loss, pain, or redness Detached retina (the light-sensitive part of the back of your eye might get pulled off) Cataract (clouding of the eye’s lens) Glaucoma (increased eye pressure) Hypotony (reduced eye pressure) Retina or cornea damage Bleeding within the eye Some patients...
Mar 19, 2023
| Consent Form
...the back of your eye might get pulled off) Cataracts (clouding of the eye’s lens) Glaucoma (increased eye pressure) Hypotony (reduced eye pressure) Retina or cornea damage Bleeding within the eye Some patients taking this medication have had heart attack, stroke, or death. The FDA does not know if the...
May 10, 2023
| Consent Form
...for Comanagement after LAL Cataract Surgery Patient Name: ____________________________ Date of Birth: ___________ Patient Confirmation I understand that my ophthalmologist, Dr. ______________, will be performing eye surgery on me and optometrist, Dr. ________________, will be co-managing my postoperative care. My surgeon has discussed this postoperative care selection with me and...
Mar 9, 2023
| Consent Form
...of the eye’s lens (cataracts) · High eye pressure (glaucoma) · Low eye pressure (hypotony) · Damage to the cornea (clear covering of the front of the eye) · Bleeding in the eye (vitreous hemorrhage) · Bright redness in the white part of the eye · Eye irritation, inflammation, and...
Nov 23, 2016
| Consent Form
...not be able to read printed words more clearly just because you had blepharoplasty. Talk with your ophthalmologist about other ways to improve vision such as with eyeglasses, contact lenses, cataract surgery, or LASIK surgery. It is your choice whether to have blepharoplasty. Here are some other options: · You...
Jun 6, 2019
| Consent Form
...require eye drops, laser treatment, or surgery · Poorly healing or non-healing wounds, which may require additional surgery · Corneal clouding and scarring, which may require additional surgery · Cataract (clouding of the natural lens), which may require immediate or eventual removal of the lens · Double vision, which may...
Mar 28, 2022
| Consent Form
...(an immune response that can cause swelling, pain, or redness in the eye) detached retina (the light-sensitive part of the back of the eye pulls away from its normal position) cataracts (clouding of the eye’s lens) glaucoma (increased eye pressure) hypotony (reduced eye pressure) damage to the retina or cornea...
Mar 19, 2023
| Consent Form
...pre-injection preparation procedure, include, but are not limited to: Eye redness Eye pain Vision loss Cataract (clouding of the lens of the eye) Glaucoma (increased pressure in the eye) Hypotony (reduced pressure in the eye) Vitreous floaters Vitreous hemorrhage Inflammation or damage to the cornea or other parts of the...
May 9, 2023
| Consent Form
...eye pulls away from its normal position) Cataract (clouding of the lens of the eye) Glaucoma (increased pressure in the eye) [bookmark: _GoBack]Damage to the retina or cornea (the clear, protective layer in the front of the eye) Vitreous hemorrhage (bleeding inside the eye) Inflammation inside the eye that can...
Mar 13, 2020
| Consent Form
...Your vision may get worse. · Avastin injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s lens) · Glaucoma (increased eye pressure) · Hypotony (reduced...
Mar 13, 2020
| Consent Form
...are: · Vision loss · Blindness · BEOVU might not improve your vision. Your vision may get worse. · BEOVU injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts...
These are sample forms—download, review and revise as needed.