Amniotic Membrane Consent Form

First Name *

Last Name *

Amniotic membranes are human tissue donated for medical purposes, specifically to aid in the healing and reconstruction of the ocular surface. They are used as dressings to promote the recovery process. Amniotic membranes are recommended for various conditions such as acute chemical or thermal burns, recurrent corneal erosion, persistent corneal epithelial defects, filamentary keratitis, vernal keratoconjunctivitis, dry eye, microbial keratitis, nodular degeneration, Stevens Johnson Syndrome, post-infectious corneal inflammation, corneal ulcers, pterygium, band keratopathy, bullous keratopathy, and PRK, among others.

Although it is not possible to guarantee absolute safety of the tissue, the procurement and processing of donor tissue follow the standards set by the American Association of Tissue Banks and the FDA. Thorough screening for diseases is conducted, and the tissue is obtained with fully informed consent.

Maintaining a healthy ocular surface is crucial for proper eye function. In the cases mentioned earlier, sutureless amniotic membranes have proven to be beneficial in controlling inflammation, minimizing scarring, and promoting epithelialization. While alternative treatments exist for the mentioned conditions, your doctor has determined that using an amniotic membrane is likely to result in the most successful resolution of your condition. Amniotic membranes are generally well tolerated by patients, although some common side effects include blurred vision and mild irritation.

I have been educated about the purpose and usage of amniotic membranes in treating my condition. I understand that while it cannot guarantee a successful outcome, an amniotic membrane is likely to facilitate proper healing and maximize the recovery of my eye. I give my consent to my eye doctor to utilize this medical technology. By signing below, I confirm that this information has been explained to me, and any queries I had regarding the procedure have been addressed.

Signature *