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
60
resources.
Jul 1, 2015
| Consent Form
...use for toric IOL and relaxing incisions www.omic.com/astigmatism-correction/ · Presbyopia correction: use for presbyopia-correcting IOLs and monovision www.omic.com/presbyopia-correction/ · Laser-assisted cataract surgery: use for laser-assisted cataract surgery or laser relaxing incisions www.omic.com/laser-assisted-cataract-surgery/ · Remove the paragraph about relaxing incisions if you are using the laser without creating one (e.g., implantation...
Feb 13, 2020
| Consent Form
...causes a painless loss of eyesight. In some cases, it can lead to blindness. About Laser Trabeculoplasty Surgery Your ophthalmologist (eye surgeon) recommends Laser Trabeculoplasty surgery. The ophthalmologist will use a laser to open the drainage system in your eye (trabecular meshwork). The surgery helps the fluid flow out of...
Apr 4, 2016
| Consent Form
...both laser and anti-VEGF injection to treat ROP. Your Ophthalmologist Is Recommending Laser Surgery. Ophthalmologists have been treating ROP with laser surgery for many years. This type of laser surgery is called PRP (pan-retinal photocoagulation). The laser stops the eye from making more of the VEGF chemical. When successful, the...
Feb 13, 2020
| Consent Form
...out of your eye. · [Include a statement:] This is an elective procedure. You do not have to have Laser Suture Lysis. Benefits How will Laser Suture Lysis treat my vision and/or condition [How can this medication help]? The goal of laser suture lysis is to lower your eye pressure...
Oct 9, 2014
| Consent Form
...at all times during the laser energy applications. 2. Flash Fires – Utilization of laser energy always raises the possibility of fire-related incidents. These are rare and are preventable by careful maintenance of the surgical equipment and stringent laser safety precautions. Possible Short-term Effects of CO2 Laser Skin Resurfacing Surgery:...
Oct 9, 2014
| Consent Form
...problems that could occur following the procedure.] Risks What are the main risks of Retina Laser Surgery (Retinopexy)? There is no guarantee that retina laser surgery will improve your condition. Sometimes it doesn’t work. In addition, retina laser surgery is risky. Sometimes it can make the problem worse, cause an...
Feb 13, 2020
| Consent Form
...monitor your [condition] and to watch for other eye problems. · [State any minor problems that could occur following the procedure.] Risks What are the main risks of Laser Iridoplasty surgery? There is no guarantee that Laser Iridoplasty surgery will improve your condition. Sometimes it doesn’t work. In addition, Laser...
Feb 13, 2020
| Consent Form
...Laser Iridotomy Surgery Your ophthalmologist (eye surgeon) recommends laser iridotomy surgery. The ophthalmologist uses a laser to create a small hole in your iris. This hole will release fluid from behind your iris. Your iris can then move away from the cornea, and your angle will open. · [Include a...
Oct 6, 2014
| Consent Form
...that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 10/06/2014 Informed Consent for GentleMAX 755/1064 Laser Treatment of Vascular and Pigmented Lesions WHAT ARE THE INDICATIONS FOR THE GENTLEMAX LASER? The GentleMAX Laser is a device that produces an intense but gentle burst...
Oct 9, 2014
| Consent Form
...that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 10/09/2014 Addendum or Insertion: “Wavefront”-Guided Laser Vision Correction Surgery Indications and Alternatives “Standard” or “conventional” laser vision correction surgery refers to correction of spherical (near- or farsightedness) and cylindrical (astigmatic) refractive errors of the...
Mar 5, 2021
| Consent Form
...record. Version 3/5/2021 [Your Letterhead] [bookmark: _GoBack]Laser Capsulotomy Surgery Consent You have [Condition], and your doctor, [Name, MD/DO], 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....
Oct 9, 2014
| Consent Form
...an iridotomy. It will take place either at the time of surgery by using an instrument (a surgical iridotomy) or within two weeks before the placement of the phakic implant by using a laser (YAG-laser iridotomy). · After your pupil has been constricted, and your eye has been anesthetized, the...
Apr 7, 2007
| Consent Form
...IntraLasetm laser to create a flap with laser energy. The IntraLase laser is capable of creating extremely precise flaps by producing tiny bubbles inside the cornea that are 1/10,000 of an inch in diameter. The laser beam cannot penetrate into the eye beyond the cornea. After the flap is created,...
Mar 9, 2023
| Consent Form
...for laser surgery. In other babies, the abnormal blood vessels are too far back in the eye to perform laser surgery safely. Other parts of the eye or blood in the eye may block the view to the abnormal blood vessels, making it impossible to perform the laser surgery. As...
Feb 13, 2020
| Consent Form
...laser energy can be delivered in different ways: · Trans-scleral approach. The ophthalmologist places the laser on the sclera (white wall of the eye), and the laser energy goes through the eye. The laser may damage the sclera. · Endoscopic approach. The ophthalmologist makes a small incision (cut) in the...
Feb 13, 2020
| Consent Form
...that lower the eye pressure with the fewest risks to the patient’s eyesight and overall health. · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or...
Oct 9, 2014
| Consent Form
...tissue back on the eye after the laser treatment, using sutures, according to the ALK procedure method. It is also possible that the flap incision could result in an incomplete flap, or a flap that is too thin. If this happens, it is likely that the laser part of the...
Oct 9, 2014
| Consent Form
...which can compromise vision. During the re-treatment procedure, after the original flap is lifted, or after the microkeratome or IntraLase laser cuts a new flap, the flap is flipped over out of the way, and the laser application is performed within the corneal bed instead of on the corneal surface...
Apr 16, 2012
| Consent Form
...combines the creation of a flap with the microkeratome or a laser and the removal of tissue with the excimer laser. PRK involves removing the surface cells on the cornea (“epithelium”) and using the excimer laser to remove tissue from the exposed tissue on the corneal surface. Both procedures have...
Feb 12, 2020
| Consent Form
...pressure with the fewest risks to the patient’s eyesight and overall health. • Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. • If medications and laser treatment do not work well enough, or if patients have trouble...
Oct 9, 2014
| Consent Form
...you have obtained informed consent. 1. Keep the original in the patient’s medical record. Version 10/09/2014 [bookmark: _GoBack] Consent for LASIK (Laser In Situ Keratomileusis) Retreatment By Lifting the Original Flap INTRODUCTION It is our hope to fully inform you about the indications, side effects, limitations, and complications of repeat...
Oct 9, 2014
| Consent Form
...that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 10/09/2014 CONSENT FOR PHOTOTHERAPEUTIC KERATECTOMY Dr. has described to me a procedure called Phototherapeutic Keratectomy (PTK). PTK is done by using the Excimer Laser. The Excimer Laser is used to remove scars, smooth the...
Nov 7, 2019
| Consent Form
...incisions www.omic.com/astigmatism-correction/ · Presbyopia correction: use for presbyopia-correcting IOLs and monovision www.omic.com/presbyopia-correction/ · Femtosecond laser: use for laser-assisted cataract surgery or laser relaxing incisions www.omic.com/laser-assisted-cataract-surgery/ These are sample consent forms. OMIC policyholders are not required to use it. Be sure to review it and modify it to suit your actual...
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...
Feb 13, 2020
| Consent Form
...patient’s eyesight and overall health. Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and...
Feb 13, 2020
| Consent Form
...alternatives are there for my condition (choices and options)? Express Shunt surgery is not the only option. Your other treatment choices may include: · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser...
Feb 13, 2020
| Consent Form
...overall health. · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and other...
Feb 13, 2020
| Consent Form
...health. · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and other difficulties,...
Feb 12, 2020
| Consent Form
...drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and other difficulties, then glaucoma surgery is...
Feb 21, 2020
| Consent Form
...choices may include: · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and...
Aug 4, 2020
| Consent Form
...choices may include: · Usually eye drop medications or laser surgery are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of cost, side effects, and...
Feb 13, 2020
| Consent Form
...the patient’s eyesight and overall health. · [bookmark: _GoBack]Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or if patients have trouble using eye drops because of...
Aug 27, 2024
| Consent Form
...use for toric IOL and relaxing incisions www.omic.com/astigmatism-correction/ · Presbyopia correction: use for presbyopia-correcting IOLs and monovision www.omic.com/presbyopia-correction/ · Laser-assisted cataract surgery: use for laser-assisted cataract surgery or laser relaxing incisions www.omic.com/laser-assisted-cataract-surgery/ You may want to create forms for astigmatism, presbyopia, or laser-assisted surgery that contain both the main consent...
Aug 27, 2024
| Consent Form
...and relaxing incisions www.omic.com/astigmatism-correction/ · Presbyopia correction: use for presbyopia-correcting IOLs and monovision www.omic.com/presbyopia-correction/ · Laser-assisted cataract surgery: use for laser-assisted cataract surgery or laser relaxing incisions www.omic.com/laser-assisted-cataract-surgery/ · You may want to create forms for astigmatism, presbyopia, or laser-assisted surgery that contain both the main consent form and the...
Oct 9, 2014
| Consent Form
...to permanent scarring and loss of vision that may require corrective laser surgery or, if very severe, corneal transplantation. o Keratoconus: Some patients develop keratoconus, a degenerative corneal disease affecting vision that occurs in approximately 1/2000 in the general population. While there are several tests that suggest which patients might...
Feb 13, 2020
| Consent Form
...that lower the eye pressure with the fewest risks to the patient’s eyesight and overall health. · Usually eye drop medications or laser therapy are used first. Often, multiple medications are needed to get the desired pressure level. · If medications and laser treatment do not work well enough, or...
Jun 6, 2019
| Consent Form
...by the initial trauma or, after the initial trauma, by lid squeezing or eye rubbing · Loss of portions of the eye (cornea and sclera), which may require grafts or removal of the eyeball · Retinal tears and detachment, which may require laser treatments or additional surgery, or may be...
Dec 9, 2020
| Consent Form
...your eye that contains the retina and the macula. It is filled with a gel called the vitreous. The vitreous is removed using suction. The ophthalmologist then performs an additional procedure. Your ophthalmologist recommends a vitrectomy for one of these reasons: Treat the retina with a laser. Remove fibrous or...
Aug 25, 2024
| Consent Form
...irregularly shaped cornea; instead of being round like a basketball, the cornea is shaped like an American style football. This can make your vision blurry. In addition to toric IOLs, astigmatism can be reduced by glasses, contact lenses, and refractive surgery (Laser assisted in situ keratomileusis [LASIK] or Photorefractive keratectomy...
Oct 6, 2014
| Consent Form
...Hylaform, Cosmoderm and Perlane. Aside from these treatments, additional options for the correction of lines and wrinkles do exist, including facial creams, BOTOX® Cosmetic (Botulinum Toxin Type A), chemical peels, and laser skin surface treatments, and surgery. Other options not mentioned here may exist. All options should be discussed with...
Dec 1, 2002
| Consent Form
...list all risks and complications that may occur. The main risks and complications of [procedure/treatment]PRK are: PRK in eyes with more than 4 D of astigmatism: I understand that the FDA approval of the excimer laser for PRK was based on attempting to correct eyes with no more than 4...
Dec 9, 2020
| Consent Form
...for one or more of these reasons: Flatten the retina where it detached. The retinal surgeon may place a scleral buckle, heavy liquid (perfluorocarbon), gas bubble, or oil to help the retina stay attached. Treat the retina with a laser or freezing treatment (cryopexy). Remove blood from the vitreous. Remove...
Feb 13, 2020
| Consent Form
...for eye drops, laser treatment, or another operation · Abnormal collection of fluid in the eye, with the need for another surgery · Worse or lost vision · Pressure that is too low · Damage to the eyeball or structures inside the eye such as the iris or the lens...
Feb 13, 2020
| Consent Form
...need for eye drops, laser treatment, or another operation · Worse or lost vision · Pressure that is too low · Damage to the eyeball or structures inside the eye such as the iris or the lens · Infection · The need for more surgery · Bleeding in the eye...
Feb 13, 2020
| Consent Form
...2 of 3 · Failure to control eye pressure, with the need for eye drops, laser treatment, or another surgery · Abnormal collection of fluid in the eye, with the need for another surgery · Worse or lost vision · Pressure that is too low · Damage to the eyeball...
Feb 13, 2020
| Consent Form
...ophthalmologist cannot tell you about every risk. Here are some of the most common and serious risks: · Failure to control eye pressure, with the need for eye drops, laser treatment, or another surgery · Abnormal collection of fluid in the eye, with the need for another surgery · Worse...
Feb 13, 2020
| Consent Form
...performed. Your ophthalmologist cannot tell you about every risk. Here are some of the most common and serious risks: · Failure to control eye pressure, with the need for eye drops, laser treatment, or another surgery · Abnormal collection of fluid in the eye, with the need for another surgery...
Feb 13, 2020
| Consent Form
...Page 1 of 2 2 Page 3 of 3 · Failure to control eye pressure, with the need for eye drops, laser treatment, or another surgery · Abnormal collection of fluid in the eye, with the need for another surgery · Worse or lost vision · [bookmark: _GoBack]Pressure that is...
Feb 13, 2020
| Consent Form
...with the need for eye drops, laser treatment, another injection, or eye surgery · Worse or lost vision · Damage to the eyeball · Infection, soon after the injection, or months or years later · Inflammation · Cataract or clouding of the lens (except if you have already had cataract...
Nov 21, 2014
| Consent Form
...sometimes even the excimer laser in a procedure called PTK (phototherapeutic keratectomy). The cornea can be scraped if the lesions are superficial, or a deeper excision called a superficial keratectomy may be indicated · Mitomycin-C (MMC) maybe used during excision (removal) to minimize the recurrence of anterior basement corneal dystrophy,...
These are sample forms—download, review and revise as needed.