MINTO OPHTHALMIC HOSPITAL

Name: Age/sex: Ip no. Date

Address:

Declaration by patient:

I have been informed in my mother tongue the condition of my ……. Eye: Chronic dacryocystitis and the
proposed procedure external dacryocystorhinostomy under local anesthesia. This involves making a
direct communication between the lacrimal passage and the nose.

I have been explained the need for and possible complications of local anesthesia like pain, infection,
injury to nerves, injury to muscles, blood vessels, arrhythmia, anaphylactic reaction, anaphylactic shock,
heart block, injury to lids, eyes, etc.

I have been explained the need for and possible complications of procedure like infection, bleeding,
wound gaping, failure of procedure, injury to nerves, injury to angular vein, need for re-procedure,
damage to nasal bone, stricture formation, narrowing of nasal flap, need for nasal pack for next 24 hrs,
cosmetic deformity, scarring, keloid formation, canalicular stricture, need for regular follow up etc.

I have understood the above and give our written informed consent and do not hold the hospital, staff,
management, doctors responsible for any untoward events.

Signature of patient:

Signature of Attender:

Relationship:

Date:

Address:

Declaration by doctor:

I declare that I have explained the nature of the procedure to be performed and discussed the risks that
particularly concern the patient. I have given the patient and opportunity to ask questions and I have
answered these.

Doctor’s signature

Doctor’s name:

Date:

MINTO OPHTHALMIC HOSPITAL

Name: Age/Sex: Ip no: Date:

Address:

Declaration by the patient:

I have been explained in my own language the condition of my

And the proposed procedure enucleation

I have been explained the need for and possible complications of general anesthesia like infection, need for
intubation, injury to tongue, teeth, oral cavity, pharynx, larynx, postoperative hoarseness of voice, dryness of
mouth, need to be nil per oral 8 hrs before and 4 hrs after surgery, aspiration, aspiration pneumonia, need for
ventilator support, respiratory depression, cardiac arrhythmia, cardiac arrest, asystole, possible death.

I have been explained that the entire eye along with its coverings and part of the nerve attached to it will be
removed and replaced with an artificial prosthesis which will only serve for cosmetic purposes.

I have been explained the need for and possible complications of procedure like infection, bleding, incomplete
removal of tumour, need for re-procedure, need for prosthetic eye, contracted socket, cosmetic deformities, need
for exenteration in case of tumour spread, etc.

I have been explained that the procedure is being for therapeutic purposes and to save life and the nil visual
prognosis has been explained to me and my family.

I consent to the administration of drugs such as infusions, plasma, blood or any treatment necessary. I have been
given the opportunity to ask questions and I have also been given the option to ask for second opinion. Any tissue
or parts surgically removed may be disposed off by institution in accordance with customary practice.

I have understood the above and give my written informed consent and do not hold hospital, doctors, staff,
management responsible for any untoward events.

Patient’s sign:

Attender’s sign: Relationship: Address:

Declaration by doctor:

I declare that I have explained the nature and consequences of the procedure to be performed, a d discussed the
risks that particularly concern the patient.

Doctor’s signature

Name:

Date:
 MINTO OPHTHALMIC HOSPITAL
Name: Age/sex Ip no Date:

Address:

I have been informed in my mother tongue the condition of my

And the proposed procedure evisceration under local anesthesia

I have been explained the need for and possible complications of local anesthesia in the form of peribulbar block
such as pain, bleeding, injury to globe, raised intraorbital pressure, injury to orbital nerves, extra ocular muscles,
injury to blood vessels, injury to optic nerve by compression neuropathy, globe perforation, retrobulbar
hemorrhage, anaphylactic reaction, anaphylactic shock, arrhythmia, heart block etc.

I have been explained that the procedure involves removing the eye leaving behind a rim of tissue around the optic
nerve along with the conjunctiva.

I have been explained the need for and possible complications of procedure like infection, bleeding, incomplete
removal of tumour, need for re-procedure, need for prosthetic eye, contracted socket, cosmetic deformities, need
for exenteration in case of tumour spread, etc.

I have been explained that the procedure is being for therapeutic purposes and to save life and the nil visual
prognosis has been explained to me and my family.

I authorize Dr. and those the institute may designate as staff, associates or assistants to perform
the above mentioned surgical procedure.

I consent to the administration of drugs such as infusions, plasma, blood or any treatment necessary. I have been
given the opportunity to ask questions and I have also been given the option to ask for second opinion. Any tissue
or parts surgically removed may be disposed off by institution in accordance with customary practice.

I have understood the above and give my written informed consent and do not hold hospital, doctors, staff,
management responsible for any untoward events.

Patient’s sign:

Attender’s sign: Relationship: Address:

Declaration by doctor:

I declare that I have explained the nature and consequences of the procedure to be performed, a d discussed the
risks that particularly concern the patient.

Doctor’s signature
 MINTO OPHTHALMIC HOSPITAL
Name: Age/Sex: Ip no: Date:

Address:

I have been explained the condition of my

And the proposed procedure : exenteration under general anesthesia under nil visual prognosis.

I have been explained the need for and possible complications of general anesthesia like infection, need for
intubation, injury to tongue, teeth, oral cavity, pharynx, larynx, postoperative hoarseness of voice, dryness of
mouth, need to be nil per oral 8 hrs before and 4 hrs after surgery, aspiration, aspiration pneumonia, need for
ventilator support, respiratory depression, cardiac arrhythmia, cardiac arrest, asystole, possible death.

I have been explained that the entire eye along with its coverings and part of the nerve attached to it will be
removed and replaced with an artificial prosthesis which will only serve for cosmetic purposes.

I have been explained that the procedure involves removal of the eye and lids upto the covering of the bones in
the orbit.

I have been explained the need for and possible complications of procedure like infection, bleeding, damage to
bony socket, need for regular dressing, inability to place orbital implant, prosthesis etc., surgical site infection,
contracted socket, residual tumour cells, need for re-procedure, etc.

I have been explained that the procedure is being for therapeutic purposes and to save life and the nil visual
prognosis has been explained to me and my family.

I authorize Dr. and those the institute may designate as staff, associates or assistants to perform
the above mentioned surgical procedure.

I consent to the administration of drugs such as infusions, plasma, blood or any treatment necessary. I have been
given the opportunity to ask questions and I have also been given the option to ask for second opinion. Any tissue
or parts surgically removed may be disposed off by institution in accordance with customary practice.

I have understood the above and give my written informed consent and do not hold hospital, doctors, staff,
management responsible for any untoward events.

Patient’s sign:

Attender’s sign: Relationship: Address:

Declaration by doctor:

I declare that I have explained the nature and consequences of the procedure to be performed, a d discussed the
risks that particularly concern the patient.

Doctor’s signature
Name: Date: