Addendum Laser Surgery - DOC by ROAoRY4

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									PLACE LETTERHEAD HERE AND REMOVE NOTE.
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NOTE: THIS FORM IS INTENDED AS A SAMPLE FORM. IT CONTAINS THE
INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY
DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR
ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE
HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED
INFORMED CONSENT.
Version 12/01/02

                     [ADDENDUM TO GENERAL CONSENT FORM]
                               LASER SURGERY


Complications which could occur weeks, months, or even years later:
1. Failure to achieve intent of surgery
2. Loss of central or side vision
3. Bleeding in eye
4. Early or late increase in pressure in eye (glaucoma)
5. Corneal burns
6. Damage to lens (cataract)
7. Retinal hole
8. Collection of fluid in back of eye
9. Damage to optic nerve
10. Damage to the iris
11. Damage to an intraocular lens implant, if present
12. Loss of vision or loss of eye


Local complications of anesthesia injections around the eye:
1. Perforation of eyeball                       4. Possible drooping of eyelid
2. Destruction of optic nerve                   5. Respiratory depression
3. Interference with circulation of retina      6. Hypotension


Additional comments:




                                                                          Revised 12/2002
Patient (or person authorized to sign for patient)   Date




Witness                                              Date




                                                            Revised 12/2002

								
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