Ph: Fax: Invisioneyemd.com. Appointment Date & Time: Dear Patient:

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1 Appointment Date & Time: Dear Patient: Ph: Fax: Invisioneyemd.com We are honored that you have chosen Dr. Choi and invision Ophthalmology to provide you your medical and surgical eye care needs. To help you prepare for your upcoming visit, please read the enclosed information. 1. To make your visit as efficient as possible, please read over and complete the attached forms to bring to your appointment. You can initial the consent, but do not sign it until you have been seen by Dr. Choi on the day of surgery. 2. Please make sure that you have someone accompany you to our office and drive you home. 3. You will first come to the office for all testing, and then you will receive a map to the surgery center. 4. Included in your packet is a prescription you will need to get filled and bring to your appointment. There are three coupons you can use for the prescription; however, your pharmacy does not have to accept them. If you do not use the coupons, please bring them with you so we can give them to other patients. 5. Bring any prescription glasses that you may wear. We also suggest that you bring sunglasses; your eyes will be sensitive to light when you leave. If you would like to donate any prescription glasses, we will accept them for our Honduras mission. 6. You will be expected to pay for your surgery at the arrival of your visit. If you have any questions about the total due, please feel free to contact us. We hope this letter will help make your visit with us pleasant and efficient as possible. If you have any questions, please do not hesitate to give us a call. Again, thank you for allowing us to participate in the care of your eyes. Sincerely, Young H. Choi M.D. and Staff invision Ophthalmology Enclosures: New Patient Paperwork (if we have not yet seen you) Prescription and coupons Do Not Forget paper After surgery instructions Consent

2 Patient Information Name: Marital Status: First Middle Last Address: City: State: Zip: DOB: Social Security #: Race: Ethnicity: Language: Home #: Cell #: Alternate #: Address: Employer: Preferred Contact #: Employer Phone #: Pharmacy Pharmacy Name: Location: Phone #: Referral Source Dr. Internet : Friend: Other: Insurance Information Primary Insurance: Group #: Policy or ID #: Insured Name: DOB: Social Security #: Secondary Insurance: Group #: Policy or ID #: Insured Name: DOB: Social Security #: Responsible Party Check if same as patient Name: DOB: Relation: First Middle Last Social Security #: Phone #: Employer: #: Responsible Address: City: State: Zip: Medical History - Anxiety Circle or Check any that apply Breast Cancer End State Renal Disease Hypercholesterolemia (High Cholesterol ) Prostate Cancer Arthritis Colon Cancer GERD Hyperthyroidism Radiation Treatment Asthma COPD Hearing Loss Hypothyroidism Seizures Atrial Fibrillation (Irregular Heartbeat) Coronary Artery Disease Hepatitis Leukemia Stroke BPH Depression Hypertension (High Blood Pressure) Lung Cancer Other Bone Marrow Transplantation Diabetes HIV / AIDS Lymphoma Other Initials DOB

3 Surgeries Name of procedure Date of Surgery Surgeon Glasses and Contact Prescriptions Glasses Prescription: Right : Left : Contact Prescription: Right : Left : Type of Contacts: Soft Toric RGP Last time Contacts were worn: Ocular History - Circle or Check any that apply Allergic Conjunctivitis Diabetic Retinopathy, Proliferative Right Macular ERM Left Strabismus Lazy Blepharitis Diabetic Retinopathy, Proliferative Left Narrow Angles Right PVD Right Cataract Right Dry s Narrow Angles Left PVD Left Cataract Left Contact Lenses Glasses Glaucoma Right Ocular Hypertension Right Ocular Hypertension Left Floaters Right Floaters Left Corneal Dystrophy Right Glaucoma Left Ophthalmic Migraine Other Corneal Dystrophy Left Macular Degeneration Right Pseudoefoliation Other Diabetic Retinopathy, Background Right Macular Degeneration Left Retinal Tear Right Other Diabetic Retinopathy, Background Left Macular ERM Right Retinal Tear Left Other Ocular Surgery - Circle or Check any that apply Blepharoplasty Right Intravitreal Injections Right PRK Left Trabeculectomy Left Blepharoplasty Left Intravitreal Injections Left Ptosis Repair Right Tube Shunt Right Cataract Surgery Right LASIK Right Ptosis Repair Left Tube Shunt Left Cataract Surgery Left LASIK Left Punctal Plugs Right Yag Capsulotomy Right Initials DOB

4 Corneal Transplant Right LPI Right Punctal Plugs Left Yag Capsulotomy Left Corneal Transplant Left LPI Left Strabismus Surgery Other DSAEK Right LTP Right Retinal Laser Right Other DSAEK Left LTP Left Retina Laser Left Other Muscle Surgery PRK Right Trabeculectomy Right Other Current Ocular Review - Circle or Check any that apply Visual difficulty Driving Distorted Vision (Halos) Redness Pain or Soreness Problems with Night Vision Glare or light Sensitivity Sandy or gritty feeling Infection of or Lid Injury Loss of Side Vision Itching Tired eyes Loss of Vision Double Vision Burning Amblyopia, Crossed Lazy Blurred Vision Dryness Foreign Body sensation Dropping lid Fluctuating Vision Mucous Discharge Excess tearing or watering Keratoconus or any Corneal Disease Family History - Circle or Check any that apply ARMD Cataracts Heart Disease Macular Degeneration Stroke Arthritis CVA Hypertension (High Blood Pressure) Migraine Thyroid Disease Blindness Diabetes Kidney Disease Retinal Detachment Other Cancer Glaucoma Lupus Strabismus Other Home Medication List Home Medication (Include Strength) Directions (Dose, Route & Frequency) Initials DOB

5 Allergies & Reactions Latex Allergy/Reaction No Latex Allergy Social History Current Occupation? How many hours a day do you work on a computer? NKDA No Known Drug Allergy Other Do you drive? NO In the Day Time At Night Both Do you drink alcohol? No Occasional 1/day 2-3/day 4+/day Do you smoke? No Every Day Smoker Some Day Smoker Former Smoker Never Smoker Review of Systems - Circle or Check any that apply Poor Vision Loss of Vision Dry Mouth Diarrhea Arthritis Anxiety Allergies Pain Fever High Blood Pressure Constipation Rash Depression Hay Fever Tearing Chills Rapid Heart Beat Redness Weight Loss Congestion Burning on Urination Urinary Frequency Changing Moles Insomnia Hives Headache Diabetes Other Jaw Pain Stuffy Nose Wheezing Incontinence Seizure Thyroid Abnormalities Other Scalp Tenderness Amaurosis Fugax Ear Ache Shortness of Breath Joint Pain Stroke Bleeding Other Cough Upset Stomach Stiffness Paralysis Anemia Other Alerts - Circle or Check any that apply Allergy to Adhesive Defibrillator Premedication Prior to Procedures Allergy to Lidocaine Flomax Rapid Hear Beat with Epinephrine Artificial Heart Valve MRSA Pregnancy or Planning a Pregnancy Artificial Joints within Past Two Years Narrow Angles Pseudoexfoliation syndrome Blood Thinners Pacemaker Steroid responder Initials DOB

6 DON T FORGET!!! Contact must be left out: Soft lenses: at least 7 days prior to treatment Rigid Contact Lenses: at least 4 weeks prior to treatment The surgical packet of information you received contains treatment Consent forms. Read the forms thoroughly, initial but do night sign until you see Dr. Choi. Bring the consent with you on treatment day. The night before treatment: Please thoroughly wash the entire area around the eyes with Johnson &Johnson s Baby Shampoo. The day of treatment: Bring a driver we do not want you driving immediately after the surgery. Plan to be at the center for approximately 2-3 hours. ABSOLUTELY NO EYE or FACIAL MAKEUP for 1 day prior to surgery and for one week after surgery. Remove ALL mascara thoroughly 2 days before surgery. Thoroughly wash the entire area around the eyes with Johnson & Johnson s Baby Shampoo. ABSOLUTELY NO PERFUME, COLOGNE, OR SCENTED LOTIONS!!! You can wear deodorant. It is permissible to eat a light meal before treatment. Bring payment with you. We accept: VISA, MasterCard, Discover, Cashier s Check, Personal Check with proper ID, or Cash. If you have any questions you can reach our office at or

7 After Surgery Instructions Post Op: Your appointment for the day after surgery is scheduled for am/pm on date at Dr. s office. Medication Instructions for LASIK surgery: 1. Wash hands well. 2. Pull lower lid down 3. For drops: place one drop within lower lid pocket. If you feel you missed, place a second drop. 4. DUREZOL bottle needs to be shaken well (about 10 X) before use. 5. Close both eyes gently for one minute. 6. Wait five minutes between different prescription eye drops. 7. BRING ALL MEDICATIONS & THIS SHEET WITH YOU TO EVERY VISIT. 8. CONTINUE ALL PREOPERATIVE MEDICATIONS UNLESS INSTRUCTED OTHER WISE. Besivance Use 1 drop 4 times a day for 48 hours. After the first 48 hours drop down to 1 drop 2 times a day for 5 more days. THEN STOP. Durezol Use 1 drop 4 times a day for 48 hours. After the first 48 hours drop down to 1 drop 2 times a day for 5 more days. THEN STOP Systane Ultra Preservative free vials Use 1 drop every hour as needed for eye dryness. Begin using drops as soon as you get home. If you refrigerate the prescription drops it will help to soothe the eyes after surgery.

8 Continuation of After Surgery Instructions It is common to experience any of the following symptoms for the first hours after surgery: Extreme REDNESS, IRRITATION, BURNING, or TEARING (this usually beings about 30 minutes after surgery.) Activities Right After Surgery: Keep your eyes closed to help soothe the irritation, burning and tearing. Try to sleep for a few hours as soon as you get home. (It is okay to take Tylenol PM to help with any pain you might have after surgery) It is important to sleep with the eye shield on for about a week. Do not try to watch TV, read, text, sew or anything that will over use your eyes. (You just had surgery the eyes need to rest.) Things to Avoid: Swimming until told otherwise Sleeping next to a pet Rubbing your eyes Activities Following the First Day of Surgery: Generally, your activities will not be restricted unless instructed by the doctor. You should use common sense, however, and not perform excessive activities in the immediate post-operative period, If you are employed, your return to work date will be determined by the type of work you do. You should be able to assume most responsibilities within one week after surgery. You may bend over to pick up items of 20 pounds or less. Ladies, you may have appointments with your hairdresser and wash your hair the day after surgery. You should notice a gradual improvement in your vision as your eye heals. You may have occasional redness, dryness and slight discomfort as part of the normal healing process. If you have any questions, please call our office at

9 INFORMED CONSENT LASER VISION CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS & ASTIGMATISM USING CUSTOM ALL LASER LASIK TECHNOLOGY PROCEDURE Custom All Laser LASIK is one type of surgery used to correct the refractive errors which impair your ability to see without glasses or contact lenses. Your blurry vision is caused by the shape of your cornea. The cornea is a part of the eye that helps focus light to create an image on the retina. It works in much the same way that the lens of a camera focuses light to create an image on film. The bending and focusing of light is also known as refraction. Usually the shape of the cornea and the eye are not perfect and the image on the retina is out-of-focus (blurred) or distorted. These imperfections in the focusing power of the eye are called refractive errors. There are three primary types of refractive errors: myopia, hyperopia and astigmatism. Persons with myopia, or nearsightedness, have more difficulty seeing distant objects as clearly as near objects. Persons with hyperopia, or farsightedness, have more difficulty seeing near objects as clearly as distant objects. Astigmatism is a distortion of the image on the retina caused by irregularities in the cornea or lens of the eye. Combinations of myopia and astigmatism or hyperopia and astigmatism are common. Glasses or contact lenses are designed to compensate for the eye s imperfections. Surgical procedures aimed at improving the focusing power of the eye are called refractive surgery. In LASIK surgery, precise and controlled removal of corneal tissue by a special laser reshapes the cornea, changing its focusing power. You have been evaluated for Custom All Laser LASIK to correct your: (please circle the appropriate term(s)) NEARSIGHTEDNESS FARSIGHTEDNESS ASTIGMATISM Custom All Laser LASIK consists of two steps. In step one your surgeon will create an ultra-thin flap in the cornea by using computer controlled laser pulses, which pass through the top layers of the cornea, to form microscopic bubbles at specific locations beneath the corneal surface. These bubbles then gently separate the outer layer of the cornea, referred to as the corneal flap, from the inner layer that requires reshaping. The inner layer is called the stromal bed. This usually takes about 20 seconds. Once the corneal flap is made, the surgeon will gently lift the flap back and perform step two, which is to apply laser pulses to the stromal bed to re-shape these inner layers of the cornea. The reshaping portion of the surgery usually takes less than a 1 Page I have read and understand this page. Please Initial

10 minute. Once complete, the surgeon will fold the flap back into its normal position on the cornea, and smooth out any bubbles or wrinkles under the flap. RISKS Custom All Laser LASIK is able to correct a range of prescriptions, but we do not want you to feel we are making the procedure sound too easy, or simple, or that the procedure is perfect, or guaranteed. No surgery can be guaranteed to be 100% successful. As with any procedure, there is the risk of complications. The possible complications you may suffer include: (1) problems during the surgery, (2) problems during the first three months after surgery, and/or (3) problems more than three months after the surgery. Possible Problems During the Surgery: Corneal Flap Complications: Any corneal flap that is not of good quality results in the LASIK procedure being stopped, without any laser prescription treatment being performed. The surgeon in these cases will fold the flap tissue back on the eye, allowing it to heal for several weeks or months. In addition, irregular healing of the flap may occur and could result in a distorted cornea, and glasses or soft contact lenses may not correct your vision to its previous level before LASIK. Laser Reshaping in the Wrong Location: Although Custom All Laser Lasik is performed with advanced eye tracking systems, it is possible that the laser treatment pattern may not be centered correctly on the pupil and visual axis. Such decentration typically results in night glare symptoms, and induced astigmatism, often reducing the patient s quality of vision. Possible Problems During the First Three Months After the Surgery: Foreign Body Sensation, Glare, Haziness of Vision, Bruising: It is very common for patients to experience pain or a foreign body sensation, particularly during the first few hours following LASIK, but occasionally this may last for 2-3 days. Some patients may also experience increased sensitivity to light, or vision fluctuations, or haziness of their vision. These conditions may persist during the normal stabilization period of 1 to 3 months, but in rare cases, may be permanent. Patients may also note some red blotches, or bruising on the whites of their eyes for 2-3 weeks. Infections: Mild or severe infections is possible. Mild infection can usually be treated with antibiotics, and usually does not lead to permanent visual loss. Severe infection, even if successfully treated with antibiotics, could lead to permanent scarring of the cornea and blurred vision. Very severe cases may result in the need for a corneal transplant, or result in the loss of the eye. Diffuse Lamellar Keratitis: Diffuse Lamellar Keratitis, or DLK (also known as sands ), is a type of allergic reaction that occurs as the layer of the cornea where the laser correction was performed. It usually occurs within the first few days following LASIK, with patients Corneal Flap Striae (Wrinkles): The corneal flap is usually hinged at the top, beneath the upper eyelid, and any injury, even a minor one, during the first few days following surgery can displace it. Even a patient squeezing their eyes very tightly can occasionally move the corneal flap and produce wrinkles. If wrinkles do occur, treatment usually involves the surgeon lifting the flap and smoothing it back into alignment, sometimes sutures may be required to smooth the cornea. 2 Page I have read and understand this page. Please Initial

11 Epithelial Ingrowth: Epithelial Ingrowth is a condition where the cells on the surface of the eye, known as the epithelium, start to grow beneath the flap after the surgery. This condition may require that the corneal flap be lifted, and the area be cleaned if significant. Usually, there is no long term risk associated if managed early. If left untreated, however, the corneal flap can be damaged permanently and impair your vision. Reading Vision, Vision Aids, Muscles Imbalance: While healing occurs, temporary glasses may be required, either for distance, or for near vision. It is possible that dependence on reading glasses may increase, or that reading glasses may be required at an earlier age. If the procedure is performed on only one eye, balance problems between the two eyes may occur after surgery. This may cause eyestrain and make judging distance, or depth perception, more difficult. The first eye may take longer to heal than is usual, prolonging the time of balancing difficulties. Possible Problems More than Three Months After the Surgery: Refractive Error Not Treated Completely: Not every patient treated achieves 20/20 vision, primarily due to differences in the way people heal. Some patients find it necessary to wear glasses after the surgery. While this can be treated with an additional laser application, the ideal time for the second procedure is between 3 and 6 months after the first procedure. Irregular Astigmatism: Irregular Astigmatism following LASIK is term used to describe corneal irregularity that is not correctable with glasses. When the corneal has a significant degree of irregular astigmatism there is a loss of sharpness, crispness and clarity. In these cases, a gas permeable contact lens is needed in order to improve vision. Corneal Ectasia: A serious complication is the development of corneal ectasia. This occurs when there is a loss of corneal stability or strength, resulting in thinning and bulging of the cornea. This may be caused by genetic condition known as Keratoconus, that was undetected and accelerated by LASIK. IF a patient develops Corneal Ectasia, They may need to wear a gas permeable contact lens to correct vision, or may even require a corneal transplant. Dry : A common complaint following LASIK surgery is the increased risk of eye irritation related to drying of the corneal surface, known as dry eye. These symptoms may be temporary, lasting 1-6 months, or, on rare occasions, permanent, and may require frequent use of artificial tears or ointment, prescription medication, or other dry eye treatment methods. Although Dry sounds rather innocuous, it can be quite debilitating, affecting both vision and comfort, and patients with significant dry eye symptoms prior to surgery should avoid having LASIK. Night Glare and other Night Visual Disturbances: Immediately after refractive surgery, most patients experience night glare around headlights or other similar situations, usually described as starbursting or a halo effect around lights. Others may simply experience a general reduction in the sharpness of their vision under low-light situations, affecting their general ability to drive at night, or see will in dim light. This is usually a temporary condition that improves over 3-6 months. Patients with very high prescriptions and pre-operative night vision difficulties are at greatest risk for decreased night vision. 3 Page I have read and understand this page. Please Initial

12 Recurrent Corneal Erosions: Recurrent corneal erosion is the repeated breakdown of the epithelium in a localized area. It can be related to trauma or a genetic weakness of the cement which binds the epithelium to the corneal surface. In patients with a genetic corneal weakness known as an epithelial dystrophy, the LASIK procedure can result in a large corneal abrasion with significant pain, and slow visual healing. This is often treated using a contact lens, which acts as a bandage, and eye drops, to reduce discomfort and risk of infection. ALTERNATIVE TREATMENTS Custom All Laser LASIK is an elective procedure. It is not medically necessary for you to undergo this procedure in order for you to see. You may continue to wear glasses or contact lenses and forgo surgery altogether. Alternatively, you also might be able to have a different surgical procedure such as PRK, LASEK, or RK. PRESBYOPIA AND THE MONOVISION OPTION When we are young, the lens inside of our eye is extremely flexible, and allows us to focus easily on close objects. Over time, the lens gradually loses its flexibility, which makes it more difficult to focus on close objects. This condition is called presbyopia, and it is a normal part of the aging process that happens to everyone, even those who have never had a vision problem before. As the condition progresses, most patients being to hold things farther away, and require brighter light to see them clearly. At this stage, most patients will require reading glasses, bifocals or progressive multifocal, to help focus objects that are close. Keep in mind, though, that if you need reading glasses now, you will likely need them after refractive surgery, unless you and your physician discuss other options in advance. Monovision is a strategy to address presbyopia. This technique involves correcting one eye for distance, and the other eye for near or intermediate vision. When both eyes are open, the brain can choose to use the distance-corrected eye to see far away objects, and the near-corrected eye to see up close, eliminating the constant need for readers for many near tasks. Each patient must decide whether or not Monovision is the right choice for them, and a contact lens trial by your own eye doctor is recommended. In general, it is recognized that patients over the age of 40 should give the most consideration to Monovision. Patients who are very active in sports, or drive a great deal at night, may not be ideal candidates for Monovision, as two eyes fully correct for best distance vision provides the best balance and sharpness for these activities. If you select Monovision, your goal of seeking treatment is to allow one eye to focus for distance, and the other eye to focus for reading. While this won t eliminate the need for reading glasses, it may greatly reduce your dependence on them. Every patient must be aware that Wavefront Guided Treatment adjustments are limited to 0.75 diopters, and as such, any monovision treatment greater than 0.75 diopters will require a Non-Wavefront guided treatment to be performed on the reading eye. Monovision in general may increase the risk of night glare, and therefore, any night vision benefit obtained from Wavefront based treatments will be limited to your distance eye, as will other quality of vision advantages. 4 Page I have read and understand this page. Please Initial

13 I ELECT TO HAVE: (please circle the appropriate term) MONOVISION OR DISTANCE VISION TREATMENT OF ONE OR BOTH EYES Today, the vast majority of all refractive surgeries are performed on both eyes on the same day. Many patients prefer having both eyes done at once as it is more convenient. Further, operating on both eyes means that you avoid having an imbalance between the corrected eye and the uncorrected eye, making it far easier to drive. Many patients note improved depth perception, and faster resolution of night glare. Naturally, there are definite risks with having surgery performed on both eyes on the same day. There may be unrecognized surgical or healing complications, for example. Whether you choose to have the surgery on both eyes on the same day, or on separate days, visual recovery from laser vision correction may be as brief as one day, or take several weeks or longer, depending on your healing pattern and the development of any unforeseen problems. I ELECT TO HAVE: (please circle the appropriate term) BOTH EYES TREATED ON THE SAME DAY ONE EYE TREATED PER DAY I CONFIRM THAT EACH OF THE FOLLOWING STATEMENTS IS TRUE AND ACCURATE: I understand that Custom All Laser LASIK is an elective procedure. There is no emergency condition or other reason that requires or demands that I have it performed. There are alternatives to this surgery. I could continue wearing contact lenses or glasses and have adequate visual acuity. I also could choose a different type of refractive surgery. Initial I have received no guarantee of a successful outcome of my particular surgery. I understand the possible short- and long-term risks associated with Custom All Laser LASIK, and that there may be risks that are unknown at this time. Initial 5 Page I have read and understand this page. Please Initial

14 I understand that the correction that I can expect to gain from Custom All Laser LASIK may not be perfect. I understand that it is not realistic to except that this procedure will result in perfect vision, at all times, under all circumstances for the rest of my life. I understand that I may need glasses to refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this might occur soon after surgery or years later. Initial I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment. It is possible that dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have this surgery. I understand that if I am over 40 years of age and have both eyes corrected for clear distance vision, I will need reading glasses for may close tasks. Initial I verify that I am at least 21 years of age, that I am not pregnant or nursing and that I must abstain from using any contact lens prior to my LASIK procedure, as directed by my eye surgeon. Initial I confirm that I have disclosed my eye and general health history, including medications and allergies, to my eye doctor and eye surgeon. I confirm that I have told my eye doctor and eye surgeon if I have or have had any of the following eye conditions: glaucoma, cataracts, keratoconus, retinal or optic nerve disease, herpes simplex or herpes zoster (shingles) of the eye, lazy eye, strabismus (muscle imbalance), or prior refractive surgery. Initial Please write in the box with your own handwriting the following statement to confirm that you have understood and accept that laser vision correction is an elective surgical procedure and as with all surgical procedures, the result cannot be guaranteed. I have read and understand the above. There are risks and no guarantees and I may still need to wear glasses. 6 Page I have read and understand this page. Please Initial

15 I give Dr. Young H. Choi permission to perform Custom All Laser LASIK on me in accordance with my instructions above. PATIENT NAME (Please print) PATIENT SIGNATURE and DATE WITNESS SIGNATURE and DATE SURGEON SIGNATURE and Date 7 Page I have read and understand this page. Please Initial