3 minutes
A cataract surgery consent form can be filled out by anyone who is considering or scheduled for cataract surgery.
Patient Name
Address
Phone Number
Date of Birth
Referring Physician Name
Social Security Number
Driver's License Number
I understand that cataract surgery is a procedure to remove the cloudy lens of my eye and replace it with a clear artificial lens.
I understand that I may have some discomfort after the surgery and that my eye may water or itch. I understand that my vision may be blurry for a short time after the surgery.
I understand that I will need to use eye drops for a few weeks after the surgery.
I understand that I will need to see my doctor for a follow-up visit a week or two after the surgery.
I understand that there are risks associated with any surgery, including infection, bleeding, and reactions to the anesthesia.
I have had the opportunity to ask the doctor any questions that I have about the surgery and I understand the risks, benefits, and alternatives to the surgery.
I hereby give my consent for the doctor to perform the cataract surgery on my eye/eyes.
Patient Signature
Date