Risk Management


Consent Forms

Welcome to OMIC’s Consent Form library, a collection of loss prevention and patient education templates for ophthalmic practices. Sample Letters and Office Forms are included under the Patient or Practice categories. Questions? Suggestions? Contact us: riskmanagement@omic.com.

Consent forms in Spanish are currently being updated.

Anesthesia (2)

General Anesthesia

Regional (retrobulbar or peribulbar) anesthesia block consent form

Cataract (13)

Anticoagulant consent form

Astigmatism Correction

Cataract -Immediate Sequential Bilateral Surgery Addendum

Cataract Consent Form

Cataract Consent Form - FL Specific

Cataract Consent Forms in Plain Language

Comanagement consent form

Laser-assisted Cataract Surgery

Light Adjustable Lens Comanagement Consent

Light Adjustable Lens Consent

Presbyopia Correction

Texas Consent Requirements Effective 2020

Yag Capsulotomy

Cornea (16)

Anticoagulant consent form

Conjuctivochalasis Repair

Corneal crosslinking consent form

Corneal transplant consent form for PK, DSEK, DMEK

DSEK Corneal Transplant Surgery

Kamra inlay

Keratoprosthesis (Artificial Corneal Transplant) Consent

LipiFlow Consent Form

Open Globe Repair Consent Form and Addendum

Penetrating Keratoplasty (PK) Corneal Transplant Consent Form

Permanent Punctal Occlusion Consent Form

Pterygium Consent Form

Raindrop corneal inlay

Removal of abnormal cells from eye surface

Superficial Keratectomy Consent

Texas Consent Requirements Effective 2020

Drugs and Devices (2)

Dilating Eye Drops Consent Form

Informed Consent for Off-label Use of a Drug or Device

Emergency Room (1)

Refusal of Recommended Medical or Surgical Treatment

Glaucoma (26)

Anterior chamber paracentesis

Anterior chamber reformation

Anticoagulant consent form

Bleb revision surgery

Bundled glaucoma revision surgery

Bundled glaucoma surgery

Bundled MIGS surgery

Canaloplasty

Choroidal drainage surgery

Cyclophotocoagulation surgery

DURYSTA Implant

Express shunt

Glaucoma implant revision or removal surgery

Goniosynechialysis surgery

Goniotomy

Hydrus

iStent

Laser iridoplasty

Laser iridotomy

Laser suture lysis

Laser trabeculoplasty

Subconjunctival injection

Texas Consent Requirements Effective 2020

Trabeculectomy

Tube surgery

Xen

Neuro (2)

Anticoagulant consent form

Texas Consent Requirements Effective 2020

Oculofacial Plastic Surgery (29)

Anterior Orbiotomy Consent Form

Anticoagulant consent form

Blepharoplasty Consent Form

Botox Consent Form

Chalazion: Incision and Drainage of Chalazion Consent Form

CO2 Laser Skin Resurfacing Consent Form

Dacryocystorhinostomy (DCR) Consent Form

Ectropion Consent Form

Entropion Consent Form

Evisceration/Enucleation Consent Form

Facial Bone Repair Consent Form

GentleMAX Laser Treatment Consent Form

Juvederm Consent Form

Lagophthalmos Surgery With Gold Weight Consent Form

Latisse™ Treatment Consent Form

Lid Laceration Repair Consent Form and Addendum

Liposuction Consent

Open Globe Repair Consent Form and Addendum

Optic Nerve Sheath Fenestration Consent Form

Orbital Decompression Surgery Consent Form

Orbital Fracture Repair Consent Form

Probing and Irrigation of Tear Duct (Nasolacrimal System) of Adult Patient

Ptosis Surgery Consent Form

Punctal Plugs Consent Form (Courtesy of Bernard H. Chang, MD, a practicing ophthalmologist in Nashville, TN.)

Repair of defect after skin cancer removal consent form

Restylane Injection Consent Form

Strabismus surgery

Texas Consent Requirements Effective 2020

Tumescent Liposuction Surgery Consent Form

Pediatric (7)

Anticoagulant consent form

Consent for Proxy Forms

ROP Injection to Treat

ROP Laser Surgery to Treat

ROP Remote Digital Fundus Imaging - Telemedicine Consent

Strabismus surgery

Texas Consent Requirements Effective 2020

Retina (33)

Anticoagulant consent form

Avastin

Avastin risk to fetus

BEOVU

BEOVU potential risk to the fetus

Bilateral same-day intravitreal injections

Byooviz Consent

Cimerli Consent

Eylea

Eylea HD Sample Consent

Eylea risk to fetus

Fluorescein Angiography Consent Form

ILUVIEN Implant Consent Form

Izervay Sample Consent

Jetrea® (ocriplasmin) Consent

Kenalog consent form

Lucentis

Lucentis risk to fetus

Macugen™ Consent Form

Open Globe Repair Consent Form and Addendum

Ozurdex

Periocular Repository Corticosteriod Injections

Photodynamic Therapy with Visudyne® Consent Form

Retinal Surgery Consent Form

Retisert™ Consent form

SYFOVRE™ (Pegcetacoplan) Consent

Texas Consent Requirements Effective 2020

Time out before intravitreal injections

Triesence consent form

Vabysmo Consent

Vitrectomy

Xipere Consent

YUTIQ Implant

Refractive (25)

AK Consent Form

Anticoagulant consent form

Bilateral Phakic Implant Consent- Addendum

Bilateral Same Day RLE Surgery Consent - Addendum

Conductive Keratoplasty (CK) for Hyperopia

Conductive Keratoplasty NearVisionSM CK

Conductive Keratoplasty. Bilateral Simultaneous CK for Hyeropia

Intacs: Consent for Off-Label Therapeutic Use for Post-LASIK Ectasia

Intacs. Bilateral Simultaneous Intacs for Treatment of Myopia

Intacs™ by Keravision® for Myopia

LASIK Consent

LASIK Retreatment Consent

LASIK Retreatment Original Flap

LASIK: Assumption of post-op care

LASIK: IntraLASIK Consent Form

LASIK. Bilateral Simultaneous

Mitomycin C with Refractive Surgery

Phakic Implant Verisyse™ Informed Consent

Photorefractive Keratectomy (PRK) Consent Form

PRK: Bilateral Simultaneous

PRK. "Off-label"

PTK (Phototherapeutic Keratectomy)

Refractive Lens Exchange (RLE) Consent Form

Texas Consent Requirements Effective 2020

Wavefront Addendum

Patient (3)

Informed Choice to Not Undergo Recommended Treatment or Procedure "Not Covered Benefit" (Sample Letter)

Informed Choice to Not Undergo Recommended Treatment or Procedure "Not Medically Necessary" (Sample Letter)

Informed Refusal of Care: Consent Form

Practice (6)

COVID-19 Consent

Informed Choice to Not Undergo Recommended Treatment or Procedure "Not Covered Benefit" (Sample Letter)

Informed Choice to Not Undergo Recommended Treatment or Procedure "Not Medically Necessary" (Sample Letter)

Referral Form for Managed Care Patients

Surgery Face Sheet

Telemedicine Consent Form

Surgery (5)

*General Consent for Medical and Surgical Procedures (use with addendums)

Corneal Surgery (Addendum to General Consent)

Laser Surgery Consent (Addendum to General Consent)

Orbital and Plastic Surgery Consent (Addendum to General Consent)

Retina Surgery Consent (Addendum to General Consent Form)



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