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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