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Agreement for Dr. Janot to Provide Post-Op Care

Agreement for Dr. Janot to Provide Post-Op Care

  • I have been informed that I have cataracts and, through a comprehensive eye examination by Dr. Janot and his staff, my vision is likely to be improved by cataract extraction (surgery) with intraocular lens implant(s).  It has been explained to me that my vision cannot be adequately improved nor corrected by conventional eyeglasses or contact lenses.

    It has also been determined, and I have also noticed, that I have impairment of my visual function due to my cataracts resulting in decreased ability to read, watch TV, drive, or perform my day to day activities.

      I have had an opportunity to have all my questions answered and have been provided literature regarding cataracts, cataract surgery, and “Eye Care After Cataract Surgery” by Dr. Janot and his staff.  The risks and benefits of cataract surgery have also been explained to me and I understand that, in my case, cataract surgery is elective surgery.  I further understand that there is no guarantee that I will enjoy an improvement in my vision after cataract surgery, but testing indicates that my vision will not improve, and, will likely decrease, without cataract surgery.

    I agree that I will appoint for surgery within 3 months of my most current comprehensive examination such that there may not be an appreciable change in my visual status.  

    It is my desire to have Dr. Janot, my doctor of optometry, perform follow-up care after my cataract surgery, when my surgeon has discharged me.  I also understand the co-management protocol between Dr. Janot and the surgeon I have chosen.  I agree to keep all my scheduled appointments and will notify Dr. Janot or my surgeon if I should have any questions regarding my surgery or my healing process.

  • If the patient is unable to sign, his/her mark is also acceptable, so long as it is co-signed by the caregiver. If the patient is unable to even mark the box, a caregiver may sign in place of the patient.
  • Date Format: MM slash DD slash YYYY
  • This field only needs to be completed if the caregiver is signing or co-signing this form.
  • This field is for validation purposes and should be left unchanged.

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