Consent for Proxy Forms

Minor-aged patients are often brought to the pediatrician for non-urgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child’s extended family, such as a grandparent, aunt, noncustodial parent, stepparent, au pair or nanny.  There are two forms available to assist you with obtaining permission or consent from someone other than the custodial parent or legal guardian.

CONSENT FOR PROXY FOR NON-URGENT PEDIATRIC CARE is available for download (proxy click here).

PREAUTHORIZATION TO TREAT MINORS is available for download (pre-authorize click here).

Probing and Irrigation of Tear Duct (Nasolacrimal System) of Adult Patient

Please click on this link to download a copy of the probing and irrigation of tear duct of adult patient consent form.

Probing and Irrigation of Tear Duct (Nasolacrimal System) of Adult Patient

What is the nasolacrimal system?

The tears are produced by the lacrimal gland located in the eye socket in the upper outer corner on both sides.  The tears go onto the eyeball and drain down the nose and throat through the nasolacrimal duct drainage (tear drain) system.

What is a tear duct obstruction?

A tear duct (tear drain) obstruction occurs when one of the areas of the drainage system is blocked. In children, this occurs when a membrane blocks the drain where it enters the nose. In adults, it can be anywhere in the system. Tears cannot drain if the tear drain is not open. A blocked tear duct system can become infected and cause “pink eye” (conjunctivitis). The infection can become more serious and cause swelling of the eyelid and tissue around the eye (cellulitis).

What is the goal of probing and irrigation?

The ophthalmologist (eye surgeon) probes and irrigates the tear drain to find where the blockage is and see how much it is blocked.

How is probing and irrigation performed?

The ophthalmologist uses anesthesia eye drops to lessen the discomfort. The ophthalmologist next widens the opening called   the puncta (the two little holes in the eyelid) with a tiny metal tool. Then the ophthalmologist puts a thin metal tool through the drain) until it reaches the inner nose.

The ophthalmologist next slowly injects sterile salt solution through the drain to make sure it is open and there is no blockage.

What are the main risks of the probing and irrigation?

 As with all surgery, there are risks (problems that can happen) with. Here are some of the most common or serious risks:

• Pain
• Swelling
• Infection
• Making the blockage  worse
• The need for a different type of surgery a later date

Consent

By signing below, you consent (agree) that:

• You read this informed consent form, or someone read it to you.
• You understand the information in this informed consent form.
• The ophthalmologist or staff answered your questions about probing and irrigation of the tear duct.
• The ophthalmologist or staff offered you a copy of this informed consent form.
• You accept that you may need another probing or another type of surgery.
• You understand that there may be additional costs if you need more surgery or other treatment.

I consent to probing and irrigation of tear ducts of the:

________ Right eye     _________ Left eye   _________ Both eyes

Patient (or person authorized to sign for patient)     Date:

Time out before intravitreal injections

CLICK ON THE NAME OF THE DOCUMENT BELOW OR THE “DOWNLOAD” BUTTON TO ACCESS THE DOCUMENT.

OMIC has received reports of “wrong” events associated with intravitreal injections. These include wrong condition, wrong dose, wrong drug, wrong eye, and wrong patient.

To ensure that the correct drug and dose are injected into the correct eye every time, the ophthalmologist needs to lead a time out before each injection. A time out provides the opportunity to confirm that the patient, medical record, and ophthalmologist are in agreement.

Time-Outs For Procedures is a sample protocol that can help prevent errors.

Removal of abnormal cells from eye surface

Removal of abnormal cells from surface of eye consent form can be used when treating OSSN (ocular surface squamous neoplasia) and CIN (conjunctival intraepithelial neoplasia). It is written in plain language to make it easier for patients to understand.

We thank OMIC Director Steven I. Rosenfeld, MD, for his assistance in developing this form.

Corneal crosslinking consent form

Use the download button to save this to your computer.

This sample consent form is written in plain language.

For a discussion of the use of FDA-approved and unapproved crosslinking systems, and some risk management recommendations, see http://www.omic.com/policyholder/i-have-patients-with-post-refractive-ectasia-who-might-benefit-from-corneal-collagen-crosslinking-with-riboflavin-c3-rcxl-will-omic-cover-this-treatment/