Date/Time:

Last Name First Name Middle Name

Attending Physician:

This certifies that Dr. has duly informed me about my

medical surgical condition and the alternative courses of treatment, depending on the result of the necessary
procedure (s) tob e performed.

I hereby authorize Dr. and his/ her assistance (s) to perform

the following procedure (s) on me:

for the diagnosis and management of my condition known

as: and to administer anaesthesia and /or sedation as my
deemed necessary. I also give my consent to the Lasik Surgery Clinic nurses staff to perform their tasks in
accordance to accepted standards.

I fully understand that during the course of operation or procedure (s), unforeseen condition may be revealed that
will necessitate additional or different procedure (s) other than those listed above. I therefore, further authorize
the performance of such procedures that in the exercise of their professional judgment are necessary and
desirable to my health and welfare.

I completely warrant that I have fully disclosed my physical and or treatments to be performed on me or even
result in any complications. Any examination to be performed does not, in any way, affect or lessen my duty to
make full disclosure as provided herein.

While I expect the surgery/ procedure to be performed upon me with no less than customary standard of care and
diligence required in the practice of their medical profession, I hereby acknowledge that no guarantee has been
made to me concerning the operation, procedure, or its accompanying results.

I also understand that the Lasik Surgery Clinic assume no responsibility for providing financial or other assistance
in the event of injury or illness.

I have also been informed about the risks involved, the possibility of complications that may arise during the course
of the said procedure(s).

I confirm that the foregoing has been thoroughly discussed and have been fully explained and
understood by me, including the content of this Patient’s Consent for Medical and Surgical Procedures
and its attachments.

I hereby consent to the taking and publication of my photographs during the course of the surgery/procedure for
marketing and /or science education purposes.
 Patient Consent

My physician has answered all my questions to my satisfaction. I understand that in the event that I will
have any more questions before the operation he/she will be more than willing to answer them. I have
read (or have had it read to me) this consent for surgical/ medical procedure (s). I understand the
condition of the consent and I hereby give my consent to having the above listed procedure (s)
performed. This has been explained to me in a language I understand.

Signature of the Patient over printed name Signature of Paren/Legal Representative

Relation to patient

Date Time

CONFIRMATION

This is to confirm that I have explained the conditions stated in this consent form to the
patient/patient’s relative or legal representatives and to the best of my knowledge have made them
understand such conditions.

Signature of Attending Ophthalmologist Date Time

I believe that the significance of the above-described procedure(s) have been clearly and adequately
explained to the patient and/or his /her relative/representative.

Witness:

Patient Representative: Clinic Representative:

Relationship: Position: