You have the right and obligation to make decisions concerning your health care. Your doctor can provide you with the necessary information and advice, but because this affects you, you must enter into the decision making process.
This form has been designed to acknowledge your acceptance of treatment recommended by your doctor. Please feel free to ask any questions.
1. I hereby authorize NANCY CHEN, M.D. / KENNETH BAUM, M.D. (and any associate or assistant involved in my care) to treat the following condition(s) which has (have) been explained to me:
Professional: NASOLACRIMAL DUCT STENOSIS OF THE AFFECTED EYE(S)
Ordinary or Lay Language: NASAL LACRIMAL DUCT STENOSIS OF THE AFFECTED EYE(S)
2. The procedure(s) planned for treatment of my condition(s) has (have) been explained to me by my doctor as follows:
Professional: SURGICAL OPENING OF THE NASOLACRIMAL DUCT OF THE AFFECTED EYE(S)
Ordinary or Lay Language: SURGICAL OPENING OF THE NASAL LACRIMAL DUCT OF THE AFFECTED EYE(S)
3. I recognize that, during the course of the operation, post operative care, medical treatment, anesthesia, or other procedure, unforeseen conditions my necessitate my above named doctor, and his/her assistants, to perform such surgical or other procedures as are necessary to preserve my life or bodily functions.
4. I have been informed that there are my significant risks, such as severe blood loss, infection, cardiac arrest, and other consequences that can lead to death or permanent or partial disability, which can result from any procedure.
5. No promise or guarantee has been made to me as to result or cure.
6. I consent to the administration of (general, regional, or local) anesthesia by and anesthesiologist, by my attending physician, or by other qualified individual under the direction of a physician as may be deemed necessary. I understand that all anesthetics involve risks that may result in complications and possible serious damage to such vital organs as the brain, heart, lungs, liver and kidney. These complications may result in paralysis, cardiac arrest and related consequences or death from both known and unknown causes.
7. Any tissues or parts surgically removed may be disposed of by the center or doctor in accordance with accustomed
8. I consent to the photographing, videotaping, televising or other audio and/or visual recording of this operation, post-operative care, medical treatment, anesthesia, or other procedures for medical or scientific purposes or for the
purpose of advancing medical education, provided my identity is not revealed by the pictures, by the recording or by the descriptive texts accompanying them.
9. Also, for the purpose of advancing medical education, I consent to the admittance of observers to the operating room, during my post-operative care, medical treatment, anesthesia or other procedure(s).