Cataract Surgery Consent Form

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