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
85
resources.
Feb 13, 2020
| Consent Form
...or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters. You must follow these instructions: You can help prevent or reduce the...
Feb 12, 2020
| Consent Form
...surgery. The surgeon may need to change the plan for surgery to treat this problem or condition right away. Instructions Tell your ophthalmologist right away if you notice any other problems after a Trabeculectomy, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and...
Feb 13, 2020
| Consent Form
...sensitivity to light, eye redness, and pus or other discharge coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters. You must follow these instructions: You can help prevent or reduce the above problems by doing...
Feb 21, 2020
| Consent Form
...pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters. You must follow these instructions: You can help prevent or...
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...
Aug 27, 2024
| Consent Form
...such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters. You must follow these instructions: You...
Aug 27, 2024
| Consent Form
...correction, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters. You must follow these instructions:...
May 2, 2016
| Consent Form
...the ophthalmologist right away if you notice any other problems after the injection. Problems can include an eye infection, eye pain, blurry or decreased vision, being extra sensitive to light, eye redness, and pus or other discharge coming from the eye. You can help prevent or reduce these problems: ·...
Aug 25, 2024
| Consent Form
...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...
Oct 18, 2019
| Consent Form
...the ophthalmologist right away if you notice any other problems after the injection such as: · Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from the eye. · New or large floaters that do not go away. · Flashing lights...
Mar 13, 2020
| Consent Form
...Some floaters are drops of the oil that lubricates the syringe. These will not go away. Tell the ophthalmologist right away if you notice any other problems after the injection such as: · Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge...
Jan 25, 2018
| Consent Form
...infection · Eye or eyelid pain · Eyelid irritation (redness, burning, tearing, itching, discharge, foreign body sensation) · Changes in your vision · Sensitivity to light · Stye (a red, sore lump near the edge of the eyelid) · Swelling of the eyelid glands · Scratch on the front of...
Feb 13, 2020
| Consent Form
...· Endoscopic cyclophotocoagulation: Your ophthalmologist makes an incision (cut) and passes a light into the eye to guide the laser. The laser treat the cells in the eye that make fluid. The cells create less fluid, and your eye pressure goes down. No device is implanted. Benefits (how the surgery...
Aug 7, 2020
| Consent Form
...experience temporary hyper-pigmentation (darkening) that usually fades after several months. Some patients may have a genetic predisposition for persistent discoloration at the incision sites. Patients that have experienced hyper-pigmentation, or hypo-pigmentation (pale or light-colored scars) in the past might expect to also experience it with these incisions. Certain areas of...
Mar 19, 2023
| Consent Form
...problems after the injection, such as: · Signs of infection, which include eye pain, blurry or decreased vision, being extra sensitive to light, eye redness, and pus or other discharge coming from the eye. You must follow these instructions: • Do not rub your eyes or go swimming for 3...
Aug 8, 2024
| Consent Form
...collection may occur, but is not expected · Failure to obtain a deep swab may result in inaccurate test results I understand the antibody test collection procedure and possible risks: · A finger stick or blood draw · You may have slight discomfort where the needle punctures the skin ·...
Sep 24, 2014
| Consent Form
...normal aging, from an eye injury, or if you have taken medications known as steroids. Cataracts may cause blurred vision, dulled vision, sensitivity to light and glare, and/or ghost images. If the cataract changes vision so much that it interferes with your daily life, the cataract may need to be...
Nov 7, 2019
| Consent Form
...Cataract Surgery with IOL (Intraocular Lens) A cataract happens when the lens in your eye becomes cloudy and hard. The lens is the clear part of your eye that helps focus images. Cataracts can cause problems such as blurry or dulled vision, sensitivity to light and glare, and seeing shadows...
Oct 9, 2014
| Consent Form
...glare, ghost images, increased light sensitivity, or corneal haze in one eye, you will likely experience them in both eyes. These side effects may cause a decrease in vision or other negative effects, and some patients have elected to not have their second eye treated. By having each eye treated...
Oct 9, 2014
| Consent Form
...condition or problem for the first time during the surgery. The surgeon may need to change the plan for surgery to treat this problem or condition right away. Satisfaction: Both eyes tend to experience similar side effects. If you experience undesirable side effects such as glare, ghost images, increased light...
Oct 6, 2014
| Consent Form
...cause blurred vision, worsened or loss of vision, ocular pain, ocular surface irritation, sensitivity to light, delayed healing, scleral or corneal melt with perforation, scarring of the conjunctiva or cornea, iritis, glaucoma, cataract, and possible need for further eye surgery. If the complication happens during surgery, your surgeon may need...
Oct 6, 2014
| Consent Form
...of light that treats the abnormal vascular and pigmented blemishes (including freckles, age spots, spider veins) without permanently affecting the surrounding skin. WHAT ARE THE POTENTIAL BENEFTS OF TREATMENT? Lesions usually fade slowly over time as the treated vessels or areas of pigmentation are eliminated by normal post-treatment healing. Immediately...
Nov 9, 2016
| Consent Form
...the patient wishes but most do very well with light sedation. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death. PATIENT’S ACCEPTANCE OF RISKS · I understand that...
Nov 9, 2016
| Consent Form
...placed into a vein in your arm or pills taken before surgery. Deeper anesthesia can be provided if the patient wishes but most do very well with light sedation. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures, loss of vision,...
Nov 9, 2016
| Consent Form
...a needle placed into a vein in your arm or pills taken before surgery. Deeper anesthesia can be provided if the patient wishes but most do very well with light sedation. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures, loss...
Nov 9, 2016
| Consent Form
...that you have obtained informed consent. 1. Keep the original in the patient’s medical record. Version 11/9/2016 INFORMED CONSENT FOR SKIN CANCER SURGERY REPAIR (Repair of defect after skin cancer removal) WHY MIGHT I NEED SURGERY AFTER SKIN CANCER REMOVAL? Skin cancer in light-skinned people is relatively common. In order...
Oct 6, 2014
| Consent Form
...the skin, bruising, redness, itching, pain, tenderness, or slight swelling. · Injections into the lip area could trigger a recurrence of facial cold sores (Herpes simplex infections) for patients with a history of prior cold sores. Precautions and contraindications If the complication happens during surgery, your surgeon may need to...
Oct 6, 2014
| Consent Form
...of complications including, but not limited to, pain, blurry or decreased vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all post-operative appointments or scheduled telephone calls so my doctor can check for complications. ________ Patient initials PATIENT CONSENT The above explanation has...
Oct 9, 2014
| Consent Form
...experience similar side effects. If you experience undesirable side effects such as pain, glare, ghost images, increased light sensitivity, or corneal haze in one eye, you will likely experience them in both eyes. These side effects may cause a decrease in vision or other negative effects, and some patients have...
Oct 8, 2014
| Consent Form
...or tearing · Sensitivity to bright light or glare · Astigmatism (a temporary blurring or distortion of your vision) for several days after the procedure. This type of visual distortion is normal during the healing process and, in most cases, it decreases overtime. However, in rare instances, it may be...
Oct 9, 2014
| Consent Form
...vision and tearing following the procedure. · You may be sensitive to bright light or glare following the procedure. · You may experience astigmatism (a temporary blurring or distortion of your vision) for several days after the procedure. This type of visual distortion is normal during the healing process and,...
Oct 8, 2014
| Consent Form
...two eyes will usually be restored more rapidly if they are operated on the same day. Satisfaction: Both eyes tend to experience similar side effects. If you experience undesirable side effects such as glare, ghost images, increased light sensitivity, or corneal haze in one eye, you will likely experience them...
Oct 9, 2014
| Consent Form
...decreased vision from direct blocking of the visual axis, leading to severe irregular astigmatism · Pyergium can be blinding condition, especially in sub-tropical and tropical climates, if work outside, or are in bright sunlight · Pterygium treatment · Excise the lesion · Perform a conjunctival-limbal autograft · Recurrence rate 1...
Oct 9, 2014
| Consent Form
...It is recognized that a minority of patients treated with conventional laser treatment describe some visual difficulties after their treatment, including glare, haloes around lights, diminished comfort at night, and ghosting of images (among other things). Data presented to the FDA suggests that a significant amount of these adverse visual...
Feb 13, 2020
| Consent Form
...to change the plan for surgery to treat this problem or condition right away. Instructions Tell your ophthalmologist right away if you notice any other problems after Glaucoma revision surgery, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge...
These are sample forms—download, review and revise as needed.