Informed consent form for myopia management

This informed consent form for myopia management is downloadable MS Word template resource which can be edited as you prefer, to print onto plain paper or your own practice letterhead paper.

After editing, the total length is around 3 pages (A4/Letter Size) for printing and/or saving as PDF, plus scientific references.

Myopia Profile retains no copyright over this content and allows you to change, add or omit content as you prefer, to suit your practice requirements.

This template resource is currently only available in English.


Supporting you in best practice myopia management

This informed consent form for myopia management is a template resource supplied by Myopia Profile to support you in developing your own consent form. It is provided as a MS word document for you to edit, add and omit content as you require. It is pre-formatted for you to print immediately on plain paper, or to copy over for printing onto your own practice letterhead paper. You could also save it as a PDF to email to patients, and/or use the text on your practice website.

Myopia Profile retains no copyright over this content to allow your preferred edits. This template resource is currently only available in English.

This template is designed to provide you comprehensive, parent-suitable information, with scientific references. You can then tailor this to your needs (for example, treatment availability) and print it onto plain paper or on your own practice letterhead paper. The informed consent form includes short text sections in lay person language on the following topics.

  • What is myopia?
  • Why is myopia a concern?
  • Why manage myopia in children? (Short-term and long-term benefits are described)
  • Treatments for slowing myopia progression. (An overview of treatment type, risks, safety and benefits are provided, with scientific references and without using product names)
  • Informed Consent for Treatment signature panel, for parent and practitioner acknowledgement.

An abbreviated and full version of the scientific references is also provided, with live hyperlinks. In editing this template resource to create your own informed consent form, it is strongly suggested that some form of scientific referencing is included. While using this content to develop your informed consent form, keep in mind that alongside suiting your practice and patient demographic, an ideal informed consent form should include background on myopia, treatment options and their risks and benefits.

This free download can also be found in our online course Communicating the Myopia Message which includes further content on the process of Informed Consent for clinical treatment and off-label prescribing.

How to Use

There are notes and instructions on the document in bold red text – make sure to read and then delete these before printing. To use this resource:

    Download the MS Word document

    Copy-and-paste it to your practice letterhead paper, and edit it suitable to your practice requirements, OR

    Delete the red instructional text, make your required edits and print it on plain paper as it is already formatted for this.

We expect that you may need to make edits to this document suitable to your practice requirements based on:

    Availability of treatments in your practice

    Whether an Informed Consent for Clinical Treatment signature block is required or advised in your country of practice, and

    In which format you prefer the scientific references to be presented. When making your preferred edits, we strongly suggest that you maintain the scientific references with the content (eg. do not delete them entirely) to ensure you are providing accessible evidence-based information and informed consent to parents and guardians.


This resource is provided to you in MS Word form, designed to be edited by you as required, and then printed by you using a standard in-office printer onto your preferred paper.

It is expected that most eye care practitioners would print this onto plain white or letterhead paper (A4 / Letter size). Professional printing capacity is not required and it can be printed in black-and-white. After editing, it is expected that the Informed Consent form would run over 3-4 pages.