Intraocular Lens Repositioning Consent Form
Please review the details below and provide your consent for intraocular lens repositioning.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Consent
*
-
Month
-
Day
Year
Date
Please confirm you are being considered for intraocular lens repositioning.
*
Yes, I am being considered for this procedure.
I have read and understand the risks, benefits, and alternatives of intraocular lens repositioning as explained to me.
*
I acknowledge and understand.
Questions or concerns about the procedure (optional)
Consent Declaration
*
Signature of Patient or Legal Representative
*
Submit Consent
Submit Consent
Should be Empty: