Excision of Eyelid Cyst Consent Form

Excision of Eyelid Cyst Consent Form
Condition and Proposed Treatment
Your ophthalmologist has evaluated you and diagnosed you with a cyst in your eyelid, which is a localized space filled with either fluid or mucus. There are several reasons for an eyelid cyst to form, most of the time it is a benign lesion but it could also be cancer. Most of the time an eyelid cyst does not resolve on its own, it needs to be surgically removed. After local anesthesia, a small scissor is used to excise the cyst from your eyelid, no pain, minimum bleeding should occur.

Alternatives to Surgery
No Treatment – I may choose no treatment and tolerate the eyelid cyst.

Risks and Complications
No procedure is entirely risk free. Adverse effects may include:
1. Infection – Infections can be treated with topical or oral antibiotics.
2. Bleeding – Normally controlled with gentle pressure or heat cautery at the incision site.
3. Pain – Minimal and resolves with healing of incision.
4. Recurrence –may recur.
5. Loss of lashes in the involved area.
6. Eyelid notching in the area of the excision.
7. Damage to the globe from the scalpel, needle used to inject the anesthetic, or cautery instrument.
8. Vision loss, including blindness (very rare or never).
Consent for Treatment
By signing below I acknowledge that I have read and understand the above, and have had my questions answered by the surgeon to my satisfaction. I consent to the excision of the eyelid cyst.
This procedure will be performed on my: (check all that apply) *

RIGHT Upper Eyelid RIGHT Lower Eyelid LEFT Upper Eyelid LEFT Lower Eyelid
Signature of Patient or Legal Representative *

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Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Patient ID# *
Date *

Month Day Year
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First Name Last Name
Relationship to Patient
Witness Signature *

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Witness Name *

First Name Last Name
Physician's Signature *

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Physician's Name *
Should be Empty: