Form Doh-Mqa 1255 - Cataract Operation With Or Without Implantation Of Intraocular Lens - Florida Board Of Medicine Page 6

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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 

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