Sample Consent Form
Consent to have LASIK surgery
This information is to help you make an informed decision about having Laser Assisted in-situ Keratomileusis surgery to treat your nearsightedness, farsightedness, or astigmatism. Take as much time as you wish to make a decision about signing this form. You are encouraged to ask any questions and have them answered to your satisfaction before giving your permission for surgery. Every surgery has flaws as well as benefits and each person must evaluate this risk/benefit ratio for himself/ herself in light of the information presented in this consent form.
Spectacles and contact lenses are the most common method of correcting nearsightedness (myopia), farsightedness (hyperopia) and astigmatism. When tolerated well, they are likely to be a good alternative to LASIK surgery. Refractive surgery is continually evolving and other refractive procedures may be available as an alternative to LASIK. You should also be aware that having any refractive procedure could potentially disqualify you from some professions, including the military and certain law enforcement agencies.
LASIK permanently changes the shape of the cornea. The surgery is performed under a topical anesthetic (drops in the eye.) A one-quarter thickness corneal flap is created with an instrument called a microkeratome. The microkeratome is a specialized instrument, which is used to perform partial thickness separation of corneal tissue. The flap is then placed back and the laser is performed inside the cornea. The flap is replaced and bonds back into place without the need for stitches. The result of removing thin layers of tissue causes the center of the cornea to flatten in the case of nearsightedness, or steepen in the case of farsightedness, or become more rounded in the case of astigmatism, which changes the focusing power of the cornea. Although the goal of LASIK is to improve vision to the point of not being dependent on glasses or contact lenses, or to the point of wearing thinner (or weaker) glasses, this result is not guaranteed.
You should understand that LASIK surgery would not prevent you from developing naturally occurring eye problems such as glaucoma, cataracts, retinal degeneration or detachment. After the procedure you should avoid rubbing the eye. Your eyes may be more susceptible to traumatic injury after LASIK and protective eye wear is recommended for all contact and racquet sports where a direct blow to the eye could occur. Also, LASIK does not correct the condition known as presbyopia (or aging of the eye), which occurs to most people around age 40 and may require them to wear reading glasses for close-up work. People over 40 that have their nearsightedness corrected may find they need reading glasses for clear, close vision. LASIK does not correct double vision. If you currently wear glasses with prism to correct double vision (strabismus), or have double vision without glasses, you will still have this condition after having LASIK surgery. It is possible, however, to improve double vision with a separate surgery.
During pregnancy, your refractive error can fluctuate which could influence your results. If you know you are pregnant or attempting to become pregnant, it is important you advise your doctor immediately.
POTENTIAL RISKS OF LASIK INCLUDE:
- VISUAL SIDE EFFECTS: Complications and conditions that can occur with LASIK surgery include: anisometropia (difference in power between the two eyes); aniseikonia (difference in image size between the two eyes); double vision; hazy vision, fluctuating vision during the day and from day to day; increased sensitivity to light which may be incapacitating for some time and may not completely go away; glare and halos around lights which may not completely go away. Some of these conditions may affect your ability to drive and judge distances; therefore driving should only be done when you are certain your vision is adequate.
- OVER CORRECTION AND UNDER CORRECTION: It may be that LASIK surgery will not give you the results you desired. Many procedures result in the eye being under corrected in which case it may be possible or necessary to have additional surgery to fine tune or enhance the initial result. These results cannot be guaranteed. It is also possible your eye may be overcorrected to the point of remaining farsighted (when the eye was originally nearsighted.) it is also possible that your eye may be overcorrected to the point of remaining nearsighted (when the eye was originally farsighted.) it is also possible your initial results could regress over time. In some, but not all cases, retreatment could be considered.
- LOSS OF BEST CORRECTED VISION or LOSS OF VISION: LASIK surgery can possibly lead to loss of vision or loss of best-corrected vision, due to infection, irregular scarring, or other causes, unless successfully controlled by antibiotics, steroids or other necessary treatment. Vision loss can be due to the cornea healing irregularly which could add astigmatism and make wearing glasses or contact lenses necessary, and useful vision could be decreased or lost. Although uncommon, it is also possible you may not be able to successfully wear contacts after LASIK.
- OTHER RISKS: Additional reported complications include: corneal ulcer formation; endothelial cell loss, epithelial healing defects, ptosis (droopy eyelid), corneal swelling, retinal detachment, and hemorrhage. Complications could also arise requiring further corrective procedures including a partial (lamellar) or full corneal transplant using a donor cornea. These complications include: loss of corneal disc, damage to the disc, disc decentration and progressive corneal thinning (ectasia.) sutures may also be required which could induce astigmatism. It is also possible the microkeratome or the excimer laser could malfunction and the procedure stopped.
- FUTURE COMPLICATIONS: As LASIK surgery has been performed only since the early 1980’s, you should also be aware that there might be other complications that could occur that have not been reported before the creation of this consent form.
- POST-OPERATIVE INSTRUCTIONS: After your surgery you will be given medications and instructions to help prevent infection and control healing. It is imperative you follow ALL instructions exactly as they are given. It is also imperative that all follow-up visits be kept as directed. FAILURE TO FOLLOW UP AS INDICATED CAN RESULT IN VISUAL LOSS.
In signing this form, you are stating that you have read this consent form, and although it may contain medical terms that you do not completely understand, you have had the opportunity to ask questions and have had them answered to your satisfaction.
To assure you have understood the information presented, please copy the following statement in your own handwriting:
“I understand the information presented and am willing to accept the fact that I may need glasses or contact lenses or further surgery following LASIK to achieve my best possible level of vision.”
True/False: I may have glare in the evening, which may make it difficult for me to function at night.
True/False: I may not be able to have 20/20 vision after the procedure even with glasses or contact lenses.
I am making an informed decision in giving my permission to have Laser Assisted In-Situ Keratomileusis (LASIK) surgery performed on my right eye; left eye; both eyes.
There are at least two ways you can save tax money with LASIK / laser vision correction:
- By deducting LASIK / laser vision correction as a medical expense
- With your company's Flex Spending Plan.