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Focal Point Vision Correction
4775 Hamilton Wolfe
San Antonio, Texas 78229
Telephone: (210) 614-3600
Fax: (210) 614-3604
Email: info@focalpointvision.com
Southside
7355 Barlite, Suite 104
San Antonio, Texas 78229
Telephone: (210) 922-3600
Fax: (210) 922-3677
Email: info@focalpointvision.com |
Patient Consent
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1. As a patient, you have the right to receive as much information as you may need in order to give informed consent or to refuse the recommended course of treatment. Except in emergencies, your physician(s) will describe in language you can understand the nature of your ailment and the nature of the proposed treatment or procedure, the material risks or dangers involved, the alternate course of treatment or procedure. If you have questions, you are encouraged and expected to consult our physician(s) prior to giving your consent to such operation or procedure. You have the right to consent or refuse any proposed operation or procedure prior to its performance.
I have been given an opportunity to ask questions of my physicians about my condition, alternative forms and options of anesthesia and treatment, risks of non-treatment, the procedures to be used, the risks and hazards involved, as well as the benefits associated with the surgical, medical and/or diagnostic procedure stated below, and believe that I have sufficient information to give this informed consent.
2. I voluntarily request as my physician, and such associates, technical assistants, other health care providers and scientific observers as they may deem necessary, to treat my condition which has been explained to me as:
CATARACT RIGHT EYE / LEFT EYE
3. I understand that the following surgical procedure(s) are planned for me and I voluntarily consent and authorize the listed procedure(s):
EXTRACTION OF CATARACT WITH INTRAOCULAR LENS IMPLANT RIGHT EYE / LEFT EYE
ANESTHESIA: LOCAL/REGIONAL/MAC IV SEDATION PROCEED TO GENERAL AS DEEMED NECESSARY
4. I understand that my physician may discover other or different conditions which require additional or different procedures that those planned and authorize providers to perform such other procedures which are advisable in their professional judgment.
5. I agree to the presence of persons in the operating room there for the purpose of learning or providing technical advice as approved by my physician.
6. I understand that no warranty or guarantee has been made to me as the result or cure. Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical and/or diagnostic procedures planned for me. I realize that common to surgical, medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death.
I also realize that the following risks and hazards may occur in connection with this particular procedure:
ADDITIONAL TREATMENT AND/OR SURGERY, NEED FOR GLASSES OR CONTACT LENSES, REMOVAL OF IMPLANTED LENS, PARTIAL OR TOTAL LOSS OF VISION
PATIENT’S INITIAL THEIR PERSONAL CHOICE
I do consent to the use of blood or blood products as deemed necessary. I understand the risks and hazards associated with the use of
blood and blood products are: fever, transfusion reaction which may include kidney failure or anemia, heart failure, hepatitis, AIDS
(Acquired Immune Deficiency Syndrome) or other infections.
I request that no blood or blood products be administered notwithstanding that such treatment may be deemed necessary in the opinion of
the physician to preserve life or promote recovery. I hereby release the surgical center, its personnel and physicians from any
responsibility whatsoever for unfavorable reactions or any untoward results due to my refusal to permit the use of blood or blood
products. I fully understand the possible consequences of refusal on my part.
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In the event of any exposure injury to a physician and/or employee or the patient, I authorize that blood be drawn and tested
for Hepatitis B & C, HIV and/or AIDS. Blood testing will be done at the expense of the Center and the results of such tests will be
kept confidential
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ANESTHESIA - General – Regional – Local – Epidural - Spinal
I understand that the anesthesia involved additional risks and hazards but request the use of anesthetics for the relief and
protection from pain during the planned surgical procedure(s). I realize the anesthesia may have to be changed possibly without explanation
to me. I understand that certain complications may result from the use of any anesthetic including respiratory problems, drug reaction,
paralysis, brain damage or even death. Other risks and hazards which may result range from minor discomfort to injury to vocal cords, teeth
or eyes. I understand that other risks and hazards resulting from spinal or epidural anesthesia includes headache and chronic pain.
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I understand that DNR order is suspended during surgery.
I understand that the treating physician(s) is an independent contractor and is not an employee of this Center.
I authorize disclosure of my full name, complete address, and telephone number, date of birth and Social Security Number to manufacturers of devices subject to the Safe Medical Device Act.
I authorize the Pathology Service to dispose of any tissue that may be removed.
PATIENT/OTHER LEGALLY RESPONSIBLE PERSON SIGNATURE: _________________________________________ / _______________________
Signature Relationship
WITNESS: ____________________________________________________ DATE ________________________ TIME ___________________________
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