JIPMER - Barraquer Refractive
LASER Centre Department
of Ophthalmology
Informed consent for Collagen Cross
Linking (CXL)
Name of Patient Age/Sex
Son / Daughter of
Patient ID / Barcode
Address Sticker
Tel Date
I have been informed in my mother tongue that I/my child is suffering from corneal ectasia (keratoconus) / other disease
involving anterior part of the cornea (specify……………….). I have been explained that the disease is progressive and can lead
to thinning and perforation of my cornea.
I have been explained that I have to undergo the process of CXL, where in the epithelium (anterior most covering of the eye)
will be scraped under topical anaesthesia. Riboflavin will then be put on the eye for 20 minutes, following this, the eye will be
exposed to UV A radiations for 6 minutes. At the end of the procedure bandage contact lens will be put.
I have also been explained that, the procedure done will not reverse or cure the disease. The procedure done will only stabilize
the current condition, thus helping to prevent its progression. Therefore, I will have to follow up every 3 monthly or as advised
by the doctor. Also, inspite of the procedure there is possibility of disease progression, for which surgery could be needed.
The risks and complications in the procedure are those of infection, persistent epithelial defect, corneal haze, blurred vision. I
certify that I have fully understood the implications of the above consent and authorize the doctors to perform corneal cross
linking on my / my child’s right/left eye.
The advantages and disadvantages, risks and possible complications of the present surgery and alternative treatments have been
explained to me by my ophthalmologist. There may arise unwanted emergency situation during surgery. In that situation I give
my full authority to my treating doctor to take any necessary decision for me / my patient’s wellbeing. Although it is impossible
for the doctor to inform me about every possible complication that may occur, the doctor has answered all my questions to my
satisfaction. In signing this informed valid consent for the operation.
I am stating that I have been offered a copy of this consent.
Further, I consent to the observing, using medical record, photographing or televising of the procedure to be performed for
medical, scientific, research, education purpose and publication in scientific journals provided my identity is not revealed by the
picture or by descriptive text accompanying them. I hereby give permission to release/publish medical data and /or video/audio
record/photograph the medical current procedure and the procedures performed in subsequent/follow up visit for the
advancement of the medical knowledge.
I have read and understood the consent form, and all my queries has been answered, and I authorize my surgeon to proceed with
the operation on my ……………………. (indicate “right” or “left” eye).
Signature / Thumb Impression of Patient: ------------------------------------------
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that
particularly concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s Signature with Date
Doctor’s name
Medical Registration No.
Witness 1 Signature Witness 2 Signature
Name Name
Age / Sex Age / Sex
Phone No. Phone No.
Address Address
JIPMER - Barraquer Refractive
LASER Centre Department
of Ophthalmology
