Healthcare Pre-Lasik Consent Form

HEALTHCARE PRE-LASIK CONSENT FORM

Patient Name:    Date of Birth:    Medical Record/ID #:

Patient Information

Insurance Information

Medical History

Do you wear contact lenses? Yes No    If yes, date of last use:

Procedure Description

I acknowledge that I have been informed that LASIK (laser-assisted in situ keratomileusis) is a surgical procedure intended to reduce dependence on spectacles or contact lenses. The procedure generally includes creation of a corneal flap followed by excimer laser ablation of corneal stroma to reshape the cornea. An additional or alternative surface procedure (such as PRK) may be recommended based on corneal thickness or other clinical findings.

Risks and Complications

The following are known risks, potential complications, and possible sequelae associated with LASIK. I understand that this list is not exhaustive and that individual results vary.

Overcorrection or undercorrection requiring enhancement procedures or continued use of glasses/contacts.
Persistent dry eye symptoms, which may be temporary or chronic and may require ongoing therapy.
Night vision disturbances including glare, halos, or reduced contrast sensitivity.
Infection, which may result in scarring and permanent visual loss.
Flap-related complications including irregular flap, displacement, epithelial ingrowth, or flap striae.
Need for additional surgical enhancement(s) in the future.
Rare risk of significant loss of best-corrected vision despite treatment.
Other complications, including allergic reaction to medications or anesthetic agents.

Alternatives; No Guarantee

I understand that there are alternative treatments including observation, continued use of spectacles or contact lenses, photorefractive keratectomy (PRK), implantable lenses, or other refractive surgeries. I further understand that results cannot be guaranteed; surgery may not achieve the desired refractive result and additional procedures may be necessary.

I acknowledge that I have had the opportunity to discuss alternatives and to ask questions, and that all my questions have been answered to my satisfaction.

Anesthesia; Photographs

The procedure will be performed using topical anesthetic drops; supplemental anesthesia or sedation may be used if indicated. I consent to standard clinical photography or video recordings for clinical documentation and treatment planning. I understand that clinical photographs are part of my medical record and may be used for quality assurance and training within the practice unless I indicate otherwise in writing.

I authorize the surgeon and designated staff to perform LASIK (or alternative laser corneal procedure as clinically indicated) on my eyes as discussed.

Pre-Operative Instructions Acknowledgement

I acknowledge the following pre-operative instructions: I will remove contact lenses as directed prior to evaluation and surgery; I will not wear eye makeup on the day of surgery; I will arrange transportation home if sedation is used; I will disclose all medications and supplements to my provider.

I will remove contact lenses as instructed.
I will not wear eye makeup on day of surgery.
I will arrange transportation home if sedation is provided.

HIPAA / Privacy and Release for Insurance

By signing below I acknowledge receipt of the practice's Notice of Privacy Practices and authorize the release of relevant medical information to my insurance carrier, treating physicians, and as required for billing and treatment coordination. This authorization includes release of imaging and surgical records necessary for payment and continuity of care.

Authorization expiration date:

Consent and Certification

I certify that I have provided a complete and accurate medical history to the best of my knowledge. I have had adequate opportunity to discuss the nature, purpose, benefits, risks, and potential complications of LASIK with my surgeon. I understand that no guarantee has been made concerning the results of the procedure. I understand my financial responsibility for charges not covered by insurance.

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