Form Doh-Mqa 1255 - Cataract Operation With Or Without Implantation Of Intraocular Lens - Florida Board Of Medicine Page 5
ADVERTISEMENT
1
2
3
4
5
6questions, and I (we) understand and accept the risks, benefits, and understand the alternatives of
cataract surgery.
The surgery is on my ______________RIGHT EYE
_______________LEFT EYE
_________ I am aware of the recognized specific risks related to cataract surgery that are
described in this form.
_________ I am aware that no intraocular lens is perfect, and that I may still need to use glasses
or contacts for at least some activities or in low light regardless of the type of lens implanted. I
am aware that no intraocular lens calculation is perfect, and that it is more difficult in an eye that
has had prior corneal surgery or retinal or glaucoma surgery. I am also aware that the intraocular
lens may later need to be repositioned, replaced, or removed by way of a subsequent surgical
procedure.
On the advice of my Ophthalmologist, he/she and I choose the following premium lenses:
______Multifocal Intraocular Lens
______Toric Intraocular Lens
______Accommodative Intraocular Lens
______Monofocal/Monovision lens (Right eye near/distance; Left eye near/distance).
______Other_______________________________________
________ I understand that if during surgery, my ophthalmologist is unable to use any of the
premium lenses; I consent to the implantation of a Monofocal Intraocular Lens.
_________ I am aware of the recognized specific risks related to Limbal Relaxing Incision (LRI)
or Astigmatic Keratectomy (AK) for Astigmatism Reduction are those that are described in this
form, and I understand that any of these risks could result in loss of vision, blindness or loss of
the eye, and may require me to undergo further surgery. Furthermore, the LRI or AK may not
fully correct the astigmatism, and glasses, contacts, or another surgical procedure may be needed
to correct the vision.
_________ On the basis of the above statements, I voluntarily consent and authorize this cataract
surgery procedure.
_________ I am aware that I have the right to report adverse incidents to the Florida Board of
Medicine or the Florida Board of Osteopathic Medicine.
Patient initials _________
Page 5 of 6
Eye Surgeon’s initials __________
Date __________
DOH‐MQA 1255, 10/11, Rules 64B8‐9.017 and 64B15‐14.012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mc 176-2-a - Qualified Medicare Beneficiary (qmb)/specified Low-income Medicare Beneficiary (slmb)/qualifying Individual (qi) Income Eligibility Work Sheet - Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Form Mc 176 Qdwi - Qualified Disabled Working Individual (qdwi) Income Eligibility Work Sheet Couple Or Applicant With An Ineligible Spouse, With Or Without Child(ren)
Legal
Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over - 2017
Legal
Form De1 - Application To Have Deposit Interest Paid Without Deduction Of Dirt Where Applicant And/or Spouse Or Civil Partner Is Aged 65 Or Over
Legal
Form Mc 338 B - 250 Percent And Ssi/ssp Income Test Work Sheet For The 250 Percent Working Disabled Program-child Applying With Or Without Ineligible Parent(s)
Legal
Form Mc 176-2 B - Qualified Medicare Beneficiary (qmb)/specified Low-income Medicare Beneficiary (slmb)/qualifying Individual (qi) Income Eligibility Work Sheet Child Applying With Or Without Ineligible Parent(s)
Legal
Related Categories
Parent category: Legal