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.
May 10, 2023
| Consent Form
...which results in changes to the refractive correction of your vision. The UV light is delivered with the RxSight Light Delivery Device (LDD), either by your surgeon or by an optometrist. The number of light adjustment treatments varies from patient to patient. The adjustments will be completed when your refraction...
May 10, 2023
| Consent Form
...surgery center as verification that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 05/23/23 [Your Letterhead] Consent for Comanagement after RxSight Light Adjustable Lens (RxLAL™) Cataract Surgery Patient Name: ____________________________ Date of Birth: ___________ Patient Confirmation I understand that my ophthalmologist, Dr. ______________,...
Oct 9, 2014
| Consent Form
...with strong nearsighted glasses is not normal because of the smaller appearance of images (“minification”) and slight decrease in peripheral vision caused by the thickness of the lenses. 2. Contact Lens. While contact lenses provide higher quality and more normal vision, they have a slight risk of complications, especially if...
Apr 16, 2012
| Consent Form
...sharp vision, which may become worse in dim light or fog. It may also cause some visual side effects such as rings or circles around lights at night. It may be difficult to distinguish an object from a dark background, which will be more noticeable in areas with less light....
Nov 10, 2023
| Consent Form
...you notice any of these problems after the injection, such as: Signs of infection, which include 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 or decreased...
Oct 9, 2014
| Consent Form
...usually not affecting vision, which usually resolves over time. o Starbursting. After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around lights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light. Although...
Oct 9, 2014
| Consent Form
...or all of the time. 4. After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around lights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light. The exact cause of these visual...
Apr 7, 2007
| Consent Form
...reading or for distance vision some or all of the time. 6. After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around lights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light....
Oct 9, 2014
| Consent Form
...temporary or, on rare occasions, permanent, and may require frequent application of artificial tears and/or closure of the tear duct openings in the eyelid. 5. After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around lights, or other low-light vision problems that may interfere...
Oct 9, 2014
| Consent Form
...on rare occasions, permanent, and may require frequent application of artificial tears and/or closure of the tear duct openings in the eyelid. 5. After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around lights, or other low-light vision problems that may interfere with the...
Dec 7, 2012
| Consent Form
...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 or decreased side vision with the floaters. You can help prevent or reduce these problems. Do not rub your eyes or go...
Aug 15, 2016
| Consent Form
...a special ultra-violet (UV) light on your eye for another 30 minutes and keep adding drops. The vitamin eye drops and UV light work together to make the collagen stronger. The cornea becomes stiffer and usually stops bulging out. The goal of CXL is to stop the cornea from getting...
Mar 5, 2021
| Consent Form
...other problems after laser Capsulotomy, 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...
May 9, 2023
| Consent Form
...Tell your 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 or decreased...
Mar 13, 2020
| Consent Form
...ophthalmologist right away if you notice any other problems after ILUVIEN implant , 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...
Mar 13, 2020
| Consent Form
...after a Lucentis injection, 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...
Mar 13, 2020
| Consent Form
...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 or decreased side vision with the floaters. You can help prevent or reduce these problems. Do not rub your eyes...
Aug 4, 2020
| Consent Form
...Triesence injections, 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...
Mar 19, 2023
| Consent Form
...the injection, such as: New or large floaters that do not go away. Flashing lights or having less side vision with the floaters. 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....
Mar 19, 2023
| 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...
Oct 31, 2024
| Consent Form
...retinal detachment). Rhegmatogenous retinal detachment is a tear and separation of one of the layers in the back of the eye that senses light (retina). Call your healthcare provider or go to the emergency room right away if you see flashing lights, see a curtain or veil covering part of...
Jan 7, 2020
| Consent Form
...Transplant Surgery, 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...
Feb 13, 2020
| Consent Form
...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 the following:...
Feb 13, 2020
| Consent Form
...if you notice any other problems after Laser Iridoplasty surgery, 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...
Feb 13, 2020
| Consent Form
...if you notice any other problems after Laser Suture Lysis, 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...
Aug 25, 2024
| Consent Form
...normal aging, from an eye injury, various medical conditions or if you have taken certain medications such 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...
Nov 21, 2014
| Consent Form
...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 the following:...
Oct 9, 2014
| Consent Form
...you notice any other problems after retina laser surgery, 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...
Dec 1, 2002
| Consent Form
...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 reduce...
Mar 13, 2020
| Consent Form
...ophthalmologist right away if you notice any other problems after an Avastin injection 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...
Mar 13, 2020
| Consent Form
...after [procedure/treatment], 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...
Oct 9, 2014
| Consent Form
...sunlight and the carcinogenic (cancer-producing) effects of ultraviolet wavelengths inherent in sun exposure or the use of tanning devices. For these reasons, avoidance of sun exposure or protection against ultraviolet light damage to your skin by the use of sun-screening or sun-blocking lotions with SPF (sun-protective factor) of 30 or...
Oct 25, 2023
| Consent Form
...after the injection, such as: New or large floaters that do not go away. Flashing lights or having less side vision with the floaters. 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...
Nov 8, 2024
| Consent Form
...some: fatigue, nausea, vomiting, headache, upset stomach, light-headedness, fainting, hives, and itching. A few patients have had severe allergic reactions (anaphylaxis) or bronchospasm (which causes breathing difficulties) after FA. These conditions can be life threatening. Be sure to tell your ophthalmologist about allergies to food, dyes, or medications, and reactions...
Feb 13, 2020
| Consent Form
...Iridotomy surgery 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...
Aug 4, 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...
Jul 1, 2015
| 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...
Feb 13, 2020
| Consent Form
...right away if you notice any other problems after Anterior Chamber Paracentesis , 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...
Feb 13, 2020
| Consent Form
...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 Anterior Chamber Reformation, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or...
Feb 13, 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 Bleb revision surgery, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness,...
Feb 13, 2020
| Consent Form
...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 coming from the eye. [Example:] New or large floaters that do not go away. [Example:] Flashing lights or decreased side vision with the floaters....
Feb 13, 2020
| Consent Form
...for surgery to treat this problem or condition right away. Instructions Tell your ophthalmologist right away if you notice any other problems after Canaloplasty surgery 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:]...
Feb 13, 2020
| Consent Form
...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 can help prevent...
Feb 13, 2020
| Consent Form
...notice any other problems after of Express Shunt surgery, 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...
Feb 13, 2020
| Consent Form
...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 the...
Feb 12, 2020
| Consent Form
...notice any other problems after Goniosynechialysis surgery, 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...
Feb 13, 2020
| Consent Form
...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 above problems by...
Feb 13, 2020
| Consent Form
...ophthalmologist right away if you notice any other problems after Hydrus Microstent surgery, 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...
Feb 13, 2020
| Consent Form
...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 can help prevent...
Feb 13, 2020
| Consent Form
...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 Laser Trabeculoplasty surgery, such as: [Example:] Eye pain, blurry or decreased vision, extra sensitivity to light, eye redness, and pus or other discharge coming from...
These are sample forms—download, review and revise as needed.