Policyholder Services

New Consent Form: Permanent Punctal Occlusion Consent Form

Save this form to your computer by clicking the DOWNLOAD button above.

The permanent punctal occlusion consent form was provided by OMIC Claims and Risk Management Committee member Steven I. Rosenfeld, MD, FACS. Dr. Rosenfeld is a board-certified, fellowship-trained ophthalmologist who specializes in medical and surgical treatments of corneal conditions, infectious and inflammatory eye diseases, and all forms of laser vision correction. Dr. Rosenfeld practices with Delray Eye Associates, PA in Delray Beach, Florida.

This form is intended as a sample form. It contains information OMIC recommends you as the surgeon personally discuss with the patient. Please review it and modify to fit your actual practice.