Patient Print Name: ______________________________
Patient Signature: ______________________________
Date: __________ Time: _______
(Or person authorized to sign for patient)
Witness Print Name: ____________________________
Witness Signature: ____________________________
Date: ____________ Time: _______
Surgeon Print Name: __________________________
Surgeon Signature: _________________________
Date: ____________ Time: _______
Patient initials _________
Page 6 of 6
Eye Surgeon’s initials __________
Date __________
DOH‐MQA 1255, 10/11, Rules 64B8‐9.017 and 64B15‐14.012