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  • 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.

    1. Inadvertent injection into the choroidal or retinal circulation, emboli
    2. Perforation of the globe with permanent loss of vision/loss of eye
    3. Cataract
    4. Glaucoma (increased eye pressure) in injected/other eye that may be transient or permanent and could lead to medical or surgical treatment (i.e., excision of depot or glaucoma filtering operation)
    5. Blepharoptosis
    6. Proptosis
    7. Orbital fat atrophy, fibrosis
    8. Delayed hypersensitivity reactions
    9. Strabismus
    10. Conjunctival hemorrhage
    11. Chemosis
    12. Infection
    13. Pain from injection, syncope, adhesions, worsening of condition, Cushing’s Syndrome, pupillary dilatation

    Patient signature
    Date