Consent for Corneal Foreign Body Removal/Conjunctival Foreign Body

I, the undersigned, authorize the performance of

Removal of Corneal Foreign BodyConjunctival Foreign Body

Location:

Left EyeRight Eye

Doctor performing the procedure:

1. My physician has fully explained to me the nature, purpose, risk and benefits of the operation/procedure, possible alternative methods of treatment, the potential risks involved, and possible complications. I acknowledge that no guarantee or assurance has been given by anyone as to the result that may be obtained as a result of the operation(s) or procedure(s) to be performed.

2. My consent is given with the understanding that the operation/procedure involves risks. The more common risks include, but are not limited to, eye infection, bleeding, loss of vision, loss of eye, failure to achieve desired result, and the need for further surgery.

3. Surgical operations and special procedures all involve risks of complications, serious injury, or death, from both known and unknown causes. Therefore, except in cases of emergency or exceptional circumstances, these operations and procedures will not be performed unless I have had an opportunity to discuss them with my physician. I have the right to consent to or refuse a proposed operation or special procedure.

4. I understand the risks, benefits, and alternative to the type and method of anesthesia or sedation recommended, and I consent to the administration of such anesthesia as may be considered necessary or advisable by the physician for this surgery/procedure, unless an exception applies.

5. If complications arise, I agree to be admitted to the hospital of my physician’s choice.

6. I consent to the performance of the operation as well as other procedures in addition to or different from what was planned, whether or not arising from unforeseen conditions, which the above-named physician (or his/her associate(s) or assistant(s) may consider necessary or advisable in the course of the operation or procedure.

MY SIGNATURE BELOW CONSTITUTES MY ACKNOWLEDGMENT THAT: 1) I HAVE READ, UNDERSTAND, and AGREE TO THE ABOVE; 2) THE PROPOSED SURGERY/PROCEDURE(s) HAVE BEEN SATISFACTORILY EXPLAINED TO ME AND THAT I HAVE ALL OF THE INFORMATION I DESIRE; AND 3) I HEREBY GIVE MY AUTHORIZATION AND CONSENT.

Date Signed:

Date

PHYSICIAN’S STATEMENT: Prior to the procedure, I discussed the condition requiring treatment and the nature, purpose, risks, and benefits of the operation/procedures(s), possible alternative methods of treatment, including non-treatment, and the possibility of complications with my patient. I provided my patient with the opportunity to ask questions and answered any and all questions presented to me. I have reviewed this consent form and verified that the planned surgery/procedure is accurate.

Physician's Initials

CONSENT FOR CORNEAL FOREIGN BODYREMOVAL/CONJUNCTIVAL FOREIGN BODY