Refractive Corneal Surgery Informed Consent Form

Patient Name: {[__________FullName__________]}

Date of Birth: {[_DOB_]}

Procedure: {[_______________Procedure_______________]}

Physician:{[____Consultant____]}

Purpose: Refractive corneal surgery is performed to correct refractive errors such as nearsightedness (myopia), farsightedness (hyperopia), and astigmatism, reducing dependency on glasses or contact lenses.

Description of Procedure: During refractive corneal surgery, the shape of the cornea is altered using advanced laser technology. This reshaping allows light to focus correctly on the retina, improving vision.

Risks and Complications: While refractive corneal surgery is generally safe and effective, there are potential risks and complications, including but not limited to:

1. Dry eyes
2. Glare or halos around lights
3. Undercorrection or overcorrection of vision
4. Infection
5. Corneal haze
6. Loss of vision
7. Flap complications (for procedures involving corneal flap creation)
8. Regression of correction over time
9. Need for additional surgery

Alternatives: Alternative treatments for refractive errors include glasses and contact lenses. Other surgical options may also be available depending on the specific condition and individual factors.

Expected Outcomes: Refractive corneal surgery aims to improve vision, potentially reducing or eliminating the need for glasses or contact lenses. While many patients achieve significant improvement in vision, individual results may vary.

Patient Responsibilities: The patient is responsible for following pre-operative and post-operative instructions provided by the physician, attending follow-up appointments, and reporting any concerns or complications promptly.

I have read and understand the information provided in this consent form. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I voluntarily consent to undergo refractive corneal surgery.

Patient Signature: _________________________ Date: ______________

Physician Signature: ________________________ Date: ______________

Witness Signature: _________________________ Date: ______________