Corneal Debridement AC

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • :
  • For our Diabetic patients, please fill out the following:

  • Acknowledgement of Risks

  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Please Read and Respond

  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Procedural Risk Acknowledgement

    Risks of the procedure(s) include (but are not limited to) the following: 1. Anesthetic or sedation complications including death 2. Infection 3. Prolonged effects of anesthesia or sedation
  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial
  • Payment Acknowledgement

    An $800 surgery deposit will be due prior to drop off. Payment is due in full at pick up. Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added to payable charges for returned checks.
  • Reset signature Signature locked. Reset to sign again
    Please Sign or Initial