• 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.

    Patient Name:

    • Dr. _________________ provided me with the following information
    1. I have the following condition(s): 
    2. The doctor is recommending the following treatment:
    3. The recommended treatment involves: 
    4. The purpose of the recommended treatment: 
    5. I need to get the recommended treatment within the following time period:
    6. The consequences of not proceeding with the recommended treatment or the above described alternative(s):
    • I understand that if I do not consent to the recommended treatment, I may endanger my vision, life, or health; I nonetheless refuse to consent to it.
    • My reason for refusing this treatment is:
    Patient signature
    Date