Download 7.2.15 Surface Ablation Consent Form

Date:
Affix Patient Label
SURFACE ABLATION AGREEMENT & CONSENT FORM
Please take time to read and understand this form thoroughly before signing it.
This form is a legal document that requires your signature before you can be accepted for
treatment. It is signed by you and the treating doctor, and is witnessed at the clinic on the day
of the procedure. This form gives the doctor the right to treat you and it will cover all
subsequent treatments. This form is given to you at least 24 hours prior the treatment so you
have ample time to reconsider your procedure.
ALTERNATIVE METHODS OF CORRECTING VISION
Contact lenses and spectacles provide correction for long-sight, short-sight and astigmatism.
There are several techniques which can improve vision without spectacles or contact lenses.
One technique is Surface ablation.
Procedure to be performed under Topical Anesthesia is:
____________________________________________________________________________
Code: SJH-EC-CL/ frm 002 v1.0
Date: May 2016
Saint James Hospital – Eye Clinic
SURFACE ABLATION
This form lists the alternatives available to you and the known complications. It is given so that
you can make an informed decision about having Surface Ablation to correct or modify your
short sight, long sight or astigmatism. This information aims to produce a balanced view of
Surface Ablation and risks involved.
The following points are understood:









You are fully informed of the advantages and disadvantages and have realistic
expectations of the procedure. The doctor decides the treatment protocol, dosage and
all aspects of aftercare.
The Surface Ablation procedure requires the use of sophisticated electrical equipment
and thus as with all electrical instrumentation, it is susceptible to system malfunctions
that can be beyond our control, nonetheless, Saint James Hospital- Eye Clinic will be
taking all necessary precautions and preparations to ensure patient safety.
The Surface Ablation procedure is done to reduce or avoid the wearing of spectacles or
contact lenses.
Surface Ablation is a surgical procedure and like all surgery it is dependent on the
doctor’s skill and is not risk free. The doctor is required to make detailed records of
consultation, treatment and any advice given. Medical records are held by Saint James
Hospital-Eye Clinic on behalf of the doctor and the patient.
The results of Surface Ablation appear to be permanent but owing to natural changes of
eyesight with age, illness or long-term results, the need for spectacles may change.
Possible complications:
 Regression of refraction
 Over or under correction
 Difficulties relating to fitting of contact lenses
 Scarring
 Infection
Short term complications:
 Droopy eyelids
 Double vision
 Haze
 Induced astigmatism
 Glare or haloes
Serious complications are rare. Infection, though very uncommon, can occur and
fortunately can be treated with antibiotic medications but there may be scarring of the
cornea requiring a remedial retreatment or even surgery.
Discomfort and imbalance may be felt if only one eye is treated and headaches and
dizziness are not uncommon, together with the impairment of judging distances,
interference in reading, driving and sports.
Code: SJH-EC-CL/ frm 002 v1.0
Date: May 2016
Saint James Hospital – Eye Clinic






Should an adverse reaction occur, such as intense pain, swelling, irritation, infection, it is
your responsibility to contact us immediately. Patients should stop taking medication or
ointment if an allergic reaction occurs. PATIENT MUST NOT RUB OR TOUCH THEIR
EYES after surgery.
Visual sharpness is measured by the smallest letter readable on the eye test chart using
lenses as necessary. A risk from Surface Ablation is that Best Visual Acuity could not be
a 100% guarantee. After treatment you may still need spectacles. The laser is
programmed for very precise degrees of correction, however everybody responds
differently to the treatment, which can result in over or under correction or induced
astigmatism.
Since it is impossible to state every complication which may occur, this list remains
incomplete and is adjourned frequently so as to provide the patients with the latest
results coming from all over the world.
Secondary treatment to the same eye if necessary, may be possible, but it may carry
additional risks
Although overall results show a very high degree of patients’ satisfaction, it is not
possible to predict a result for any single individual.
The final result will be achieved after about one month. However, in some individuals, it
may take longer. Most patients attain good vision within a few days only.
Code: SJH-EC-CL/ frm 002 v1.0
Date: May 2016
Saint James Hospital – Eye Clinic
Patient Declaration
I have been advised that I should take as long as I wish before consenting to the procedure
and I am not under any pressure by either the doctors or Saint James Hospital-Eye Clinic to
have this treatment. The choice to go ahead is mine based on the benefits and drawbacks,
as explained to me both in verbal and written form.
I understand that a sedative may be given to me 30mins before the treatment commences.
On signing this form I am not under the influence of any drugs / medication and have not yet
had any eye drops administered.
I am satisfied that all of the above has been fully explained and is understood.
Patient’s Signature:
Patient’s Name in Block:
Date:
Time:
Legal Guardian/Representative/Parent
Signature:
Legal
Guardian/Representative/Parent
Name in Block:
Relationship to the Patient:
Date:
Time:
Second Witness Signature:
Second Witness Name in Block:
Relationship to the Patient:
Date:
Time:
Interpreter’s Statement
I have interpreted the information to the best of my ability, and in a way in which I believe the
patient can understand:
Code: SJH-EC-CL/ frm 002 v1.0
Date: May 2016
Saint James Hospital – Eye Clinic
Interpreter’s Signature:
Interpreter’s Name in Block:
Date:
Time:
Treating Doctor’s Declaration
I have discussed the contents of this form with the patient and I am satisfied that they
understand the meaning of the technical terms which it contains, the nature and purpose of the
procedure and the side effects and possible complications that are described. I agree to accept
this patient on the above terms and provide treatment as set out above.
Treating Doctor’s Signature:
Treating Doctor’s Name in Block:
Date:
Time:
Withdrawal of Patient Consent:
If the patient has withdrawn consent please ask the patient to sign here
Patient’s Signature:
Name of Patient in Block:
Treating Doctor’s Signature:
Name of Doctor in Block:
Date:
Time:
Code: SJH-EC-CL/ frm 002 v1.0
Date: May 2016
Saint James Hospital – Eye Clinic