Informed Consent For Cataract Surgery (Page 2 of 2) in pdf

PATIENT’S ACCEPTANCE OF RISKS

I understand that it is impossible for the doctor to inform me of every possible complication that may occur. By

signing below, I agree that my doctor has answered all of my questions, that I have been offered a copy of this

consent form, and that I understand and accept the risks, benefits, and alternatives of cataract surgery. I further

understand that an IOL implant does not necessarily replace the need for glasses and no guarantee has been

made regarding specific visual outcomes.

Option A: _____ Multifocal (Presbyopia Correcting) IOL Option

I wish to have a Femptosecond Laser assisted cataract operation with a ______________ multifocal on my

__________ eye. While a multifocal IOL is expected to decrease my need for spectacle lenses, I understand that

achieving my best possible vision may still require spectacles for far and/or near.

Option B: _____ Toric (Astigmatic) Monofocal IOL Option

I wish to have a Femptosecond Laser assisted cataract operation with a Toric monofocal IOL on my

__________ eye set for ____________ (state far or near) vision. I understand that spectacles will be definitely

be required for distances other than stated above and could even be required, though not expected, for my

indicated distance above.

Option C: _____ LRI (Astigmatic)Spherical Monofocal IOL Option

I wish to have a Femptosecond Laser assisted cataract operation with Limbal Relaxing incisions to reduce minor

to moderate astigmatism on my __________ eye with a conventional monofocal IOL set for ____________

(state far or near) vision. I understand spectacles will be required for distances other than that stated above and

could even be required, though not expected, for my indicated distance above.

Option D: _____ ORA Assisted Option

I wish to have conventional cataract surgery with a conventional IOL set for _________ (choose far or near) on

my __________ eye. I understand spectacles will be required for distances other than that stated above and

could even be required, though not expected, for my indicated distance above.

Option E: _____ Conventional IOL with Standard Cataract Extraction

I wish to have a standard cataract extraction with conventional IOL on my ___________ eye. With this option it

is expected that I will need spectacles for far and/or near.

____________________________________________

__________________________

Patient (or person authorized to sign for patient)

Date

Informed Consent For Cataract Surgery Page 2