You have been given information about your conditiona the recommended surgical, medical or diagnostic procedures(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information give to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).

Condition: Dr. Marcus A. East, M.D. Ryan W. Lapour, M.D. John G. Dodd, D.O. Adam T. Shupe, O.D. has explained to me that the following condition(s) exist in my case:

I understand that the procedure(s) proposed for evaluating and treating my condition is/are:

Right Eye         Left Eye

Just as there may be benefits to the procedure(s) proposed, I also understand that medical and surgical procedure(s) involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, blindness, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including Hepatitis and Acquired Immune Deficiency Syndrome, from the administration of blood and/or blood components.

I also realize that there are particular risks associated with the procedure(s) proposed for me and these risks include, but are not limited to, those enumerated in the addendum.

Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen condition may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment.

Acknowledgments: The available alternatives, some of which include the potential benefits and risks of the proposed procedure(s), and the likely result without such treatment, have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.

Having read this form and talked with the physicians, my signature below acknowledges that:
I voluntarily give my authorization and consent to the performance of the procedure(s) described above (including the administration of blood and disposal of tissue) by my physician and/or his/her associates by hospital personnel and other trained persons as well as the presence of observers.