Healthcare Myopia Treatment Form

HEALTHCARE MYOPIA TREATMENT FORM

Clinic Name:    Date of Visit:

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Ocular and Medical History

Date of Last Eye Exam:    Current Spectacle/Contact Prescription (Sph/Cyl/Axis):

Age at onset of myopia:    Spherical equivalent change in last 12 months:

Proposed Treatment Plan

The clinician proposes the following myopia control option(s). Please check all that apply and initial where indicated.

Low-dose topical atropine (off-label use). Initial concentration: . Planned start date: .

Orthokeratology (overnight rigid gas-permeable lenses). Trial fitting date: .

Multifocal soft contact lenses for myopia control. Planned replacement schedule: .

Myopia-control spectacle lenses. Frame trial date: .

Combination therapy (describe):

Risks, Benefits, and Alternatives

I understand that the objective of the proposed treatment is to reduce the rate of myopic progression. Potential benefits include slowing refractive change and reducing long-term risk associated with high myopia. These benefits are not guaranteed.

Potential risks include, but are not limited to: transient blurred vision, glare or halos, ocular surface dryness, allergic reaction to drops or lens care solutions, corneal staining or abrasion, corneal infection potentially resulting in loss of vision, rebound progression after cessation (particularly with pharmacologic treatment), and the need for additional procedures or discontinuation of treatment. Orthokeratology and contact lens wear carry a risk of microbial keratitis; strict compliance with care instructions reduces but does not eliminate this risk.

Reasonable alternatives include observation with standard refractive correction, behavioral or optical interventions not chosen, and deferred refractive surgery until adulthood. I have had the opportunity to ask questions and to have them answered to my satisfaction.

Consent, Authorization, and Financial Responsibility

By signing below I authorize the treating clinician and clinical staff to perform the indicated myopia control treatment(s), including instillation of diagnostic or therapeutic topical medications, contact lens fitting and dispensing, corneal topography, and imaging as necessary. I understand that certain uses of topical agents (e.g., low-dose atropine) may be off-label for myopia control and that such use has been explained to me.

I acknowledge that I am responsible for costs not covered by insurance, including contact lenses, solutions, replacement lenses, clinic visits, and any additional treatment required for complications. I agree to follow the clinician's instructions and to attend scheduled follow-ups; failure to comply may increase the risk of adverse outcomes and may require discontinuation of treatment.

I understand I may withdraw consent at any time by notifying the clinic; withdrawal will not affect care already provided. Emergency care will be arranged if a serious adverse event occurs.

I acknowledge receipt of the clinic's privacy practices and authorize use and disclosure of my protected health information for treatment, payment, and healthcare operations as necessary for my care.

I authorize the clinic to release relevant ocular health information to other providers involved in my care. Authorization expires on:

Additional Consents

I consent to pupil dilation for diagnostic purposes if required.

I consent to clinical photography and imaging for documentation and monitoring of treatment response (images become part of the medical record).

I consent to trial fitting of contact lenses as part of the treatment plan and accept responsibility for care and replacement per clinic instructions.

Provider Information

Sign Now