Consent for Laser Eye Surgery
Patient Information
Full Name
Date of Birth
Address
Procedure Information
Type of Surgery
Name of Surgeon
Date of Procedure
Risks and Complications Acknowledgment
I understand the purpose, expected benefits, and possible alternatives for laser eye surgery.
I have been informed of possible risks and complications, including but not limited to:
Vision loss or visual disturbances
Dry eyes or discomfort
Need for further treatment or corrective lenses
I have had the opportunity to ask questions and discuss concerns.
Consent Statement
I voluntarily consent to undergo laser eye surgery as described above.
I have read and understood the information provided, and all my questions have been answered.
Additional Notes
Comments or Special Instructions
Patient Signature
Date
Surgeon/Witness Signature
Date