YUTIQ Implant
The YUTIQ implant is approved for chronic non-infectious posterior uveitis. This form was created on 3/13/20.
Bilateral same-day intravitreal injections
Exercise caution when performing bilateral injections on the same day.
Obtain informed consent for bilateral injections; ask the patient to sign the Intravitreal injections.Bilateral same day consent. This was last revised on 3/6/20.
Consider the injection for each eye as a separate procedure.
Use separate site preparation, individual syringes, needles, etc.
Use a different medication batch or lot number.
Xen
This is a sample form for XEN. Click on the name of the form or the download button to access it.
This form was revised on 2/21/20 to state that Xen includes gelatin derived from pigs. Some patients may have religious reasons to decline such an implant. We recommend you disclose this information to the patient.
We would like to thank Dr. Ansari and his team at Ophthalmic Consultants of Boston for developing and sharing his practice’s glaucoma forms with us. We made some content and formatting changes.
Tube surgery
This is a sample form for Tube Surgery. Click on the name of the form or the download button to access it.
We would like to thank Dr. Ansari and his team at Ophthalmic Consultants of Boston for developing and sharing his practice’s glaucoma forms with us. We made some content and formatting changes.
