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
65
resources.
Oct 9, 2014
| Consent Form
...that other very rare complications threatening vision include, but are not limited to, corneal swelling, corneal thinning (ectasia), appearance of “floaters” and retinal detachment, hemorrhage, venous and arterial blockage, cataract formation, total blindness, and even loss of my eye. If the complication happens during surgery, your surgeon may need to...
Apr 7, 2007
| Consent Form
...detachment, hemorrhage, venous and arterial blockage, cataract formation, total blindness, and even loss of my eye. B. NON-VISION-THREATENING SIDE EFFECTS 1. I understand that there is a greater chance that the whites of my eyes may temporarily appear pink or red for several days to several weeks after surgery. This...
Oct 9, 2014
| Consent Form
...of sharp vision, increased corneal scarring, increased night glare or corneal infection. Any pre-existing viral infections may reappear with the use of post-operative drops. If the cornea has extensive scars, it is possible that a corneal perforation may occur that could produce other changes such as infections, cataracts or the...
Oct 9, 2014
| Consent Form
...feeling in the eye; double or ghost images; patient discomfort; inflammation of the cornea or iris; persistent corneal surface defect; persistent corneal scarring severe enough to affect vision; ulceration/infection; irregular astigmatism (warped corneal surface which causes distorted images); cataract; drooping of the eyelid; loss of bandage contact lens with increased...
Nov 10, 2023
| Consent Form
...some common and serious ones: IZERVAY™ will not improve your vision. Your vision may still get worse. Izervay injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of...
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 3, 2014
| Consent Form
...a miniature telescope that is inserted into a corneal transplant and stitched into the patient’s own cornea. The natural lens, if still present, is removed. If the patient has already had cataract surgery, the lens implant is left alone. A soft contact lens is then placed onto the eye for...
Oct 25, 2023
| Consent Form
...that can cause vision loss, pain, or redness Detached retina (the light-sensitive part of the back of your eye might get pulled off) Cataract (clouding of the eye’s lens) Glaucoma (increased eye pressure) Increases in intraocular (eye) pressure have been seen within 60 minutes of intravitreal injection, including with Eylea®HD...
May 2, 2016
| Consent Form
...vision may get worse. · Ozurdex injections can cause other eye problems such as: · an eye infection · glaucoma (high eye pressure) · cataracts (clouding of the eye’s lens) · detached retina (the light-sensitive part of the back of your eye might get pulled off) · [bookmark: _GoBack]hypotony (low...
Oct 6, 2014
| Consent Form
...that you have obtained informed consent. · Keep the original in the patient’s medical record. Version 10/06/2014 POTENTIAL COMPLICATIONS ASSOCIATED WITH PERIOCULAR REPOSITORY CORTICOSTEROID INJECTION(S) 1. Inadvertent injection into the choroidal or retinal circulation, emboli. 2. Perforation of the globe with permanent loss of vision/loss of eye. 3. Cataract. 4....
Oct 6, 2014
| Consent Form
...High eye pressure needs to be treated with eye drops. After about two years, many patients need surgery to control the pressure in their eye. · After about two years, almost all patient develop a cloudy lens or cataract and need to have it removed. An artificial lens is inserted,...
Oct 9, 2014
| Consent Form
...such as glaucoma, cataracts, retinal degeneration or detachment. KeraVision Intacs do not correct the condition known as presbyopia (or aging of the eye) which may require reading glasses for close-up work. · I understand that having KeraVision Intacs does not necessarily mean total freedom from eyeglasses because excellent vision without...
Oct 9, 2014
| Consent Form
...of the eye) · Damage to the lens (cataract) · Loss of vision or loss of the eye · Loss of peripheral (side) vision · Need for very thick glasses · Corneal clouding or scarring · Decrease or loss of vision caused by loss of circulation to the vital tissues...
Oct 18, 2019
| Consent Form
...injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s lens) · Glaucoma (increased eye pressure) · Hypotony (reduced eye pressure) · Retina or cornea damage...
Mar 13, 2020
| Consent Form
...or serious: · Eylea might not improve your vision. Your vision may get worse. · Eylea injections can cause other eye problems such as: · An eye infection · Detached retina (the light-sensitive part of the back of your eye might get pulled off) · Cataracts (clouding of the eye’s...
These are sample forms—download, review and revise as needed.