YAG Consent Form

After modern cataract with lens implant surgery, the back membrane of the cataract is left in place to support the lens implant. This membrane may become cloudy and cause blurred vision, and sometimes patients will see streaks or halo’s around lights. These problems worsen with time

In the past, a trip back to the operating room was necessary. A small cut was made and a needle introduced to cut the cloudy membrane. Complications of the surgery included possible infection, retinal swelling, or retinal detachment with possible loss of vision. An anesthetic injection was necessary and complications from the injection included heart or breathing disturbances, damage to the optic nerve, or perforation of the eyeball with the needle.

Fortunately, a modern YAG laser treatment can be done without a need for anesthetic injection or a small cut. Many of the complications noted previously are thereby eliminated. There is not interruption in physical activities and no patch after the laser treatment is needed.

Laser surgery is still surgery. Complications can still occur. Some new floaters or spots may be seen. Retinal swelling or detachment can follow this type of surgery as well. The eye pressure may rise temporarily after the YAG laser treatment.

THE ALTERNATIVE TREATMENTS AND THEIR RISKS AND BENEFITS HAVE BEEN EXPLAINED TO MY SATISFACTION. I HEREBY GIVE MY INFORMED CONSENT FOR A POSTERIOR CAPSULOTOMY IN MY EYE WITH THE YAG LASER.

Consent for Treatment
By signing below I acknowledge that I have read and understand the above, and have had my questions answered by NANCY CHEN, M.D. / KENNETH BAUM, M.D. to my satisfaction. I understand that this procedure will be performed IN-OFFICE at 511 Manawai St #401, Kapolei, HI 96707.

I hereby consent Dr. Nancy Chen/ Dr. Kenneth Baum to treat my

RIGHT EYELEFT EYE

1. Seeing clearly in bright lights (ex: bright sunlight)

YesNo

2. Seeing to drive at dusk or in the dark

YesNo

3. Reading traffic signs, street signs, or store signs

YesNo

4. Doing fine handwork like sewing, knitting, crocheting or carpentry

YesNo

5. Watching TV

YesNo

1. Poor night vision

YesNo

2. Seeing rings or halos around lights

YesNo

3. Glare caused by headlights or bright sunlight

YesNo

4. Hazy and/or blurry vision

YesNo

5. Seeing well in poor or dim light

YesNo

6. Poor color vision

YesNo

7. Double vision

YesNo

Patient's Signature

Patient's Name

First NameLast Name

Date of Birth

Patient ID#

Date*

If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.

Name

First NameLast Name

Relationship to Patient

Witness Signature

Witness Name

First NameLast Name

Physician's Signature

Physician's Name*

YAG POSTERIOR CAPSULOTOMY Consent Form

VISUAL FUNCTIONING

SYMPTOMS