Consent to Medical/Surgical Office Procedure

Risks and Complications
No procedure is entirely risk free. Adverse effects from the procedure 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 – the condition may recur if not treated completely.
5.   Loss of lashes in the involved area
6.   Eyelid notching in the area of the inflammation
7.   Damage to the globe from the scalpel, needle used to inject the anesthetic, or cautery instrument.
8.   Vision loss, including blindness.

I hereby authorize Nikola Ragusa, MD to perform the indicated procedure on my eye. The procedure, alternatives, risks and possible complications have been explained to me and I understand them. The risks include, but are not limited to bleeding, infection, inflammation, change in vision, amongst others. I acknowledge that no guarantee or assurance has been given to me as the results that may be obtained.