CONSENT FORM

TITLE OF THE PROJECT: COMPARISON OF EFFECTIVENESS OF TOPICAL STEROIDS

AFTER UNEVENTFUL PHACOEMULSIFICATION SURGERY FOR TWO WEEKS AND TWO
MONTHS

Patients Name: __________________ Age/Gender:____________________

Admission No:___________________ Serial No:_______________________

I hereby Authorize Dr. USSAMA ASHFAQ, to Include me in this study, which will evaluate the
patient for inflammation and ac reaction after Phacoemulsification surgery for Cataract, for 2
weeks and 2 months for the same procedure.

1. I confirm that I understand the Information for the above study

2. I have had the opportunity to consider the information, ask questions, and have had
these answered satisfactorily.
3. I understand that my participation is voluntary and that I am free to withdraw at any
time, without giving any reason, without my medical rights or legal rights being
affected.
4. I understand that relevant sections of any of my medical notes and data collected
during the study, may be looked by responsible individuals from (KEMU/ Mayo Hospital
Lahore), from regulatory authorities, where it is relevant to me taking part in this
research. I give permission to these individuals to have access to my records.
5. I agree to my GH being informed of my participation in the study.
6. I agree to take part in the above research study.

Name of the Patient:_______________ Date: _________ Signature:___________

Name of the Witness:_______________ Date: _________ Signature:___________