• Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.

    My doctor has determined that I have cataracts in both eyes, and that general anesthesia is required in order to perform the surgeries safely because _____________________________________________.

    To reduce the risks for me of having general anesthesia twice, my doctor has recommended that I have the surgery done on both eyes on the same day.

    Having both cataract surgeries done on the same day may increase the risk of having vision-threatening complications such as infection, and could lead to loss of vision or even blindness in both eyes. In addition, the planned visual outcome may not be as precise since my doctor won’t have the advantage of knowing the results from the first eye cataract surgery. My doctor will take steps to reduce the risk of complications, especially infection, in each eye.

    I am willing to accept the possible increased risk of eye complications in order to reduce the risk from having general anesthesia on two separate occasions.

    Patient signature