Botox Consent Form
Review the Botox consent form at least annually.
Cosmetic botulinum toxin and/or filler injections are frequently administered in ophthalmology practices. Sometimes, ophthalmologists are asked to provide them at a spa or “botulinum toxin and/or filler party” at a private home. The recommendations in Botox and Fillers are designed to promote patient safety and reduce the physician’s liability exposure.
Refusal of Recommended Medical or Surgical Treatment
REFUSAL OF RECOMMENDED MEDICAL OR SURGICAL TREATMENT
Patient Name:
Dr. ___________ informed me of the following:
I have the following condition(s):
The doctor recommends:
The recommended treatment consists of:
The purpose of the recommended treatment is:
I should get the recommended treatment within the following time period:
The possible alternative(s) to the recommended treatment:
The consequences of not getting the recommended treatment or the above described alternative(s):
I understand that my failure to accept the recommended treatment may endanger my vision, life, or health; I nonetheless refuse to consent to it.
My reason for refusal is:
Patient (or person authorized to sign for patient) Date
*General Consent for Medical and Surgical Procedures (use with addendums)
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GENERAL CONSENT FOR MEDICAL AND SURGICAL PROCEDURES
You have been given information about your condition and the recommended surgical, medical or diagnostic procedure(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).
Condition: Dr. has explained to me that the following condition(s) exist in my case:
Proposed Procedure(s): I understand that the procedure(s) proposed for evaluating and treating my condition is/are:
Right eye Left eye
Risks/Benefits of Proposed Procedure(s):
Just as there may be benefits to the procedure(s) proposed, I also understand that medical and surgical procedures involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, blindness, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including Hepatitis and Acquired Immune Deficiency Syndrome, from the administration of blood and/or blood components.
I also realize that there are particular risks associated with the procedure(s) proposed for me and that these risks include, but are not limited to, those enumerated in the addendum.
Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment.
Acknowledgments: The available alternatives, some of which include , the potential benefits and risks of the proposed procedure(s), and the likely result without such treatment, , have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.
Consent to Procedure(s) and Treatment: Having read this form and talked with the physicians, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the procedure(s) described above (including the administration of blood and disposal of tissue) by my physician and/or his/her associates assisted by hospital personnel and other trained persons as well as the presence of observers.
Patient (or person authorized to sign for patient) Date
Witness Date
[SEE ADDENDUM]
Dilating Eye Drops Consent Form
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Please review the form, modify it to fit your actual practice, and place on your letterhead. Please offer the patient a copy of the form. The last page serves to verify that the surgeon has obtained informed consent from the patient; it can be copied and sent to the ambulatory surgery center if needed as verification of consent. This consent form is intended as a sample only and is provided as a risk management service. It is not intended to constitute a standard of care and should not be relied upon as a source for legal advice. If legal advice is desired or needed, an attorney should be consulted.
Version 12/2/2002
INFORMATION REGARDING DILATING EYE DROPS
Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye.
Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it’s best if you make arrangements not to drive yourself.
Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.
I hereby authorize Dr. and/or such assistants as may be designated by him/her to administer dilating eye drops. The eye drops are necessary to diagnose my condition.
Patient (or person authorized to sign for patient) Date
Witness Date
