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Version 12/11/20

Consent for regional anesthesia block

[Name of surgery] surgery is performed under regional anesthesia. Anesthetic medicine is injected around the eye to numb the eye and keep it from moving. The ophthalmologist, anesthesiologist, or nurse anesthetist may also give you intravenous sedation to help you relax. 
•	Risks of regional anesthesia include needle damage to the eyeball or optic nerve, which could cause loss of vision; interference with circulation of the retina, which could cause loss of vision; drooping of the eyelid; double vision; and bruising of the skin around the eyes.
•	Intravenous sedation can cause heart and breathing problems. Very rarely, it can cause death.

By signing below, you consent (agree) that:
•	You read this informed consent form or had it read to you.
•	You were told that you will have a regional block for anesthesia.
•	Your questions about this type of anesthesia have been answered. 
•	You consent to have the ophthalmologist perform a regional block on your ___________ (“right,” “left”) eye. 

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Patient Signature (or person authorized to sign for patient)			Date