Consent Forms in Ophthalmic Practice

1 Consent Forms inOphthalmic PracticeinHindi & EnglishEDITORSE nglish EditionDr. Bhavna ChawlaDr. Namrata SharmaDr. Lalit VermaHindi EditionDr. NegiDr. GuptaPublished By:Dr. Amit KhoslaSecretary, DOSRoom , 2nd FloorNew BuildingSir Ganga Ram HospitalRajinder Nagar, New delhi - 110060 DisclaimerThis manual is for educational purpose only and is not intended to constitute legaladvice. Hence it should not be relied upon as a source for legal Detachment------------------------------ ---------------------------------------- ------------------------------------ Retinal Surgery Hole Surgery ---------------------------------------- ---------------------------------------- --------------------- Intravitreal Injection ---------------------------------------- ---------------------------------------- ----------- Intravitreal Injection ---------------------------------------- ---------------------------------------- --------- Intravitreal Injection ---------------------------------------- ---------------------------------------- ---------- Laser

2 ---------------------------------------- ---------------------------------------- ----------------------------------- Indirect Ophthalmoscopy ---------------------------------------- ---------------------------------------- --------- Photocoagulation for Diabetic Retinopathy ---------------------------------------- ---------------------------- Photocoagulation for Proliferative Retinopathy ---------------------------------------- ------------------------ Photocoagulation for Maculopathy ---------------------------------------- -------------------------------------- Fluorescein Angiography / Ophthalmoscopy/ Indocyanine Green Angiography ----------------------- Therapy (PDT) ---------------------------------------- ---------------------------------------- ---------- Pupillary Thermotherapy (TTT)

3 ---------------------------------------- ---------------------------------------- - Injection for Endophthalmitis ---------------------------------------- -------------------------------------- Tests ---------------------------------------- ---------------------------------------- ---------------- 59 OCULOPLASTY & ---------------------------------------- ---------------------------------------- ---------------------------------- and Probing ---------------------------------------- ---------------------------------------- --------------------- Plugs ---------------------------------------- ---------------------------------------- ------------------------------- (DCR)----------------------------------- ---------------------------------------- -------------- Socket---------------------------------- ---------------------------------------- ------------------------------- 87 OCULAR SURFACE, CORNEA & REFRACTIVE Penetrating Keratoplasty ---------------------------------------- ---------------------------------------- --------- Keratoplasty ---------------------------------------- ---------------------------------------- ----------------- Lamellar Therapeutic Keratoplasty (ALTK) ---------------------------------------- --------------------- Anterior Lamellar Keratoplasty (DALK)

4 ---------------------------------------- --------------------------------- s Stripping Endothelial Keratoplasty (DSEK/DSAEK) ---------------------------------------- ---------- Keratectomy (PTK) ---------------------------------------- ---------------------------------------- - Keratectomy (PRK) ---------------------------------------- ---------------------------------------- --- 1078 .LASIK---------------------------------- ---------------------------------------- ---------------------------------------- ---- Keratotomy (AK)------------------------------------ ---------------------------------------- ---------------- IOL ---------------------------------------- ---------------------------------------- --------------------------------- Keratoplasty ---------------------------------------- ---------------------------------------- ----------------- Surgery--------------------------------- ---------------------------------------- ------------------------------- Scraping ---------------------------------------- ---------------------------------------- -------------------------- Glue Adhesive for Corneal Perforation ---------------------------------------- -------------------------------- Release

5 ---------------------------------------- ---------------------------------------- ------------------- Membrane Transplantation (AMT) ---------------------------------------- --------------------------------- Stem Cell Transplantation (LSCT) ---------------------------------------- ------------------------------------ Keratoprosthesis (OOKP) ---------------------------------------- -------------------------------------- Surgery ---------------------------------------- ---------------------------------------- ---------------------------- (Botulinum Toxin) Injection ---------------------------------------- ---------------------------------------- ----- With / Without Anti-Fibroblastic Agents ---------------------------------------- ------------------ Laser Cyclo-photocoagulation (DLCP) ---------------------------------------- -------------------------------- Laser Trabeculoplasty (ALT)

6 ---------------------------------------- ---------------------------------------- --- Iridotomy ---------------------------------------- ---------------------------------------- --------------------------- Surgery With / Without Implantation of Intraocular Lens ---------------------------------------- ------- Cataract ---------------------------------------- ---------------------------------------- ------------------------- Capsulotomy----------------------------- ---------------------------------------- ----------------------------------- Under Anesthesia (EUA) ---------------------------------------- ---------------------------------------- - Iridectomy ---------------------------------------- ---------------------------------------- ------------------------ 183 RETINA( 1 )CryosurgeryBipul Baishya, Atul KumarName of Patient.

7 Patient ID .. Date ..Son / Daughter of .. Tel ..Proposed TreatmentThe doctor has explained that I, (name of patient ..), have a retinal lesion in which is a risk factor fordevelopment of .. and Cryosurgery is are the commoner risks. There may be other unusual risks that have not been listed understand there are risks associated with any anesthetic agent (in case of children).I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and understand the procedure has the following specific risks and most retinal lesions can be treated, it is not 100% effective. In some cases, more than two sittings may be detachment or macular puckering that may require additional in eyeLocal complications of anesthesia injections around the eye of of optic with circulation of drooping of RisksI understand the following are possible significant risks and complications specific to my individual circumstances, that I have consideredin deciding to have this operation.

8 Declaration by PatientI acknowledge doctors from the Ophthalmic team have informed me about the procedure, alternative treatments and answered myspecific queries and concerns about this acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstancesthat I have considered in deciding to have this understand that a doctor other than the specialist surgeon may perform the procedure.( 2 )I have received no guarantee the operation will be have received a copy of this form to take home with a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and otherblood borne understand I will be advised and counselled as soon as practicable after the operation if this has been / Thumb Impression of Patient/ Parent / Guardian.

9 Name:.. :..Phone (Off ) ..(Res).. (Mob) ..Declaration by DoctorI declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularlyconcern the have given the patient an opportunity to ask questions and I have answered s signatureDoctor s nameDateWitness 1 Witness 2 Signature: ..Signature: ..Name: ..Name: ..Address: ..Address: ..Tel: ..Tel: ..( 3 ) kvks ltZjhfciqy cS';] vrqy dqekjjksxh dk uke %..mez@fyax %..jksxh dh vkbZMh %..rkjh[k %..dk iq=@iq=h ..irk % ..VsyhQksu ua %..izLrkfor mipkjMkWDVj us Li"V fd;k gS fd esjh ---------------------------------------- ---------------------------------------- --------- jksxh dk uke ---------------------------------------- ---------------------------vka[k esajsfVuk ls tqM+k t[e gS tks fd ---------------------------------------- ----------------- ds fodkl ds fy, tksf[ke dk dkjd gS vkSj k;ks ltZjh izLrkfor dh gSAtksf[ke;s tksf[ke gSaA nwljs vlkekU; tksf[ke Hkh gks ldrs gSa ftUgsa fd ;gka lwphc) ugha fd;k x;k gSAeSa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkFk cPpksa ds ekeys esa tksf[ke tqM+s gksrs gSaAeq>s mi;ksx esa yk;h x.]]]]]]]

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