Please list any: allergies to medications: previous surgeries: diseases or medical conditions: medications you are currently taking:

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Please list any: allergies to medications: previous surgeries: diseases or medical conditions: medications you are currently taking:"

Transcription

1 4909 S. 118th St. Omaha, NE ( 402) (800) (402) fax Eval Meas date time Location: Omaha Sioux City Surgery date Arrival time SX time Location: Omaha Sioux City : Pt. ID: Name: Birthdate: / / _ Age: Address: City: _ State: Zip: Home phone: Work / Cell Phone: Sex: M F Who is your current eye doctor? Do you currently wear contact lenses? Yes* / No *If Yes : Rigid OR Soft How did you hear about Nebraska Laser Eye Associates? OD WOM Radio Newspaper Television Mailing Internet Walk-in Other Price: Folder sent: Patient Employer: Patient Occupation: address: Spouse Name: Personal Ocular History Personal Medical History Do you have? Yes No Do you have? Yes No Cataracts Diabetes Glaucoma Heart disease Eye Injury Autoimmune Disease Lazy Eye Arthritis Keratoconus HIV Retinal Disease Depression Dry Eyes Currently Pregnant / Nursing Other eye surgery Latex Allergy Bleeding tendency Please list any: allergies to medications: previous surgeries: diseases or medical conditions: medications you are currently taking: Converted 09/27/10

2 PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon execution of this Consent. This Consent was signed by: Patient or Patient Representative In front of: Practice Representative

3 4909 S. 118 th St., Omaha, NE fax LASIK FOLLOW-UP RELEASE Patient Name My surgeon, Dr. Mark Johnston, has given me, and I have read, the instructions regarding proper eye care following Laser Vision Correction (LASIK or PRK) surgery. I have informed Dr. Johnston that it would be more convenient for me to have my post-operative care performed by my own eye doctor, Dr.. I have discussed this with my eye doctor and he/she is willing to perform these services in conjunction with my surgeon and will keep Dr. Johnston informed of my progress. I understand that I am to contact Dr. Johnston at any time with any questions or problems. I understand that if I should choose to return to Dr. Johnston for the remainder of my post-operative care, I may do so at any time. I am aware that a percentage of the LASIK fee collected on the day of surgery may be forwarded to my referring eye doctor for their pre- and post-operative care. Patient Signature Witness

4 A PATIENT S BILL OF RIGHTS At Johnston Ambulatory Surgery Center, LLC (JASC) we believe our patients have certain rights when visiting our office as well as certain responsibilities to our office. This is a summary of these rights and responsibilities: As our patient, you have the right to: 1. Respectful and safe care by competent personnel; 2. Be informed of patient rights during the admission process; 3. Be informed in advance about care, treatment and related risks; 4. Make informed decisions regarding care and treatment and to receive information necessary to make those decisions; 5. Refuse care, participation in experimental research and treatment and to be informed of the medical consequences of refusing such; 6. Every consideration of his/her privacy concerning his/her medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly involved in his/her care must have permission of the patient to be present; 7. Expect that within its capacity, this accredited ambulatory surgery facility must provide evaluation service and/or referral as indicated by the urgency of the case. When medically permissible, a patient may be transferred to another facility only after he/she has received complete information and explanation concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer; 8. Obtain information as to any relationship of this facility to other health care and educational institutions insofar as his/her care is concerned. The patient has the right to obtain information as to the existence of any professional relationships among individuals, by name, who are treating him/her; 9. Expect reasonable continuity of care. He/she has the right to know in advance what appointment times and physicians are available and where. The patient has the right to expect that this facility will provide a mechanism whereby he/she is informed by his physician of the Patient s continuing health care requirements following discharge; 10. Be advised in advance of the estimated fees related to your care and payment accommodations; 11. Be free from abuse, neglect and harassment; 12. Receive health services without discrimination; 13. Voice complaints and grievances without discrimination or reprisal and have those complaints and grievances addressed. 14. Receive treatment in a smoke free environment. You have the responsibility to: 1. Provide complete and accurate information about your past illnesses, medications, allergies and current health status. 2. Follow the pre-operative and post-operative instructions you will receive from the staff of JASC. 3. Cooperate with the treatments and nursing care provided once you understand the purpose. 4. Assure that the financial obligations for care are fulfilled as promptly as possible If you have any questions, suggestions, complaints or grievances please contact Jennifer Fischer, RN, BSN Mark Johnston, MD (402) (402) Nebraska Health and Human Services Medicare Ombudsman (402)

5 Associates Is owned and operated by: Mark Johnston MD PC Mark E Johnston MD FRCSC Ambulatory Surgery Center Is owned and operated by: Johnston Ambulatory Surgery Center LLC Mark Johnston MD FRCSC John G Goertz OD FAAO For your convenience, private pay patients will pay only Mark Johnston MD PC. Your fees will then be disbursed, according to usual and customary fees, to the surgeon, your regular eye doctor, and the surgery center. Medicare and certain insurance plans require that a separate bill be sent by the surgeon, your own eye doctor and the surgery center. If you have any questions concerning your billing, please ask our staff for assistance. On the reverse is a copy of our Patient Bill of rights. Should you have any complaints or specific concerns which you would like to have addressed, please notify the staff. You may also note these concerns on the patient questionnaire you receive at the time of surgery. Should you wish to make a formal written complaint, please note that we have policies in place to assure that these receive serious consideration. Please address these to our Office Manager. Our staff would be happy to assist you in preparing such a written grievance. You should expect to receive a written reply within fourteen days of our receipt of your written complaint. Advance Directive Policy To comply with state law, during the registration process, you will be asked if you have an advance directive. Please bring a copy if you have one. If you do not have an advance directive and would like further information please call us at Upon request we will mail information regarding advance directives or will have it available to you at registration. Physician Ownership Notice The physician who is rendering services may have an ownership interest in Nebraska Laser Eye Associates. During the scheduling process, the physician's representative will give you the option to be treated at alternate facilities. If you wish to be treated at another facility please notify your physician's office. I acknowledge that I was informed in writing of my patient rights, advance directive policy, and physician ownership notice, prior to the date of my procedure. Patient

6 Informed Consent for Laser Assisted In-Situ Keratomileusis (LASIK) Introduction You are entitled to be informed about the proposed procedure, including the risks of the procedure and alternatives to it. Please read this document thoroughly and discuss the content with your physician so that all of your questions are answered to your satisfaction. By signing this form I acknowledge and I understand the following: 1. This consent is incomplete as it is impossible to list and discuss all possible complications and consequences remotely possible with LASIK, or any other surgery, within the context of this form. 2. The procedure to be performed on my eye is called Laser Assisted In-Situ Keratomileusis (LASIK). The procedure involves surgically creating a flap of corneal tissue and treating the undersurface with an excimer laser. The flap of tissue is repositioned over this treated area. No sutures are required. This procedure will create a new corneal contour, thus decreasing the amount of nearsightedness, farsightedness, or astigmatism. 3. The objective of LASIK is to reduce or eliminate nearsightedness, farsightedness, or astigmatism. 4. It is not necessary to have LASIK. It is purely an elective procedure. 5. Alternative to LASIK include: a. Spectacles (glasses) b. Contact lenses c. Photorefractive keratectomy (PRK) 6. While many people have benefited from LASIK, some people have been disappointed by the results. A few have experienced persistent complications from having had LASIK. 7. Having LASIK does not necessarily mean total freedom from corrective lenses (spectacles or contact lenses), and there is a good chance I will need to wear some sort of corrective lenses in the future. If bifocals or reading glasses are presently required, a reading prescription may still be required after this surgical procedure. Risks of Laser Assisted In-Situ Keratomileusis Vision Threatening Complications. Although unlikely, there is a possibility that a loss of some or all useful vision will occur as a result of the following: a. Infection (internal or external) that cannot be controlled by antibiotics or other means. b. Irregular healing of the cornea that could result in a distorted corneal surface so that distorted vision or ghosting occurs. This may not be correctable by spectacles or contact lenses. c. Haze or scar on the cornea or under the flap. d. Surgery may weaken the cornea, allowing a gradual development of irregularity of the surface requiring contact lenses and/ or other treatment. e. After retreatment, the vision may not be correctable by spectacles or contact lenses to a level equal to preoperative vision. f. Malfunction of the microkeratome or laser may require that the procedure be stopped before completion. g. Occlusion of a blood vessel caused by increasing the pressure within the eye during the procedure that could also cause loss of some, or all, of the visual field. h. Displacement or folds of the flap requiring repositioning. i. Debris or tissue under the flap requiring removal. j. Superficial scratching from the microkeratome may require a temporary bandage contact lens Patient initials verifying page 1 has been read and understood / /

7 Non-Vision Threatening Complications. It is expected that at least some of the following will occur: a. Farsightedness. Some hyperopia may remain after LASIK. Alternatively, overcorrection may occur resulting in a residual nearsightedness after surgery. If the surgeon feels any further enhancement would be unwise, spectacles or contact lenses may be required. b. Nearsightedness. Some myopia may remain after LASIK. Alternatively, overcorrection may occur resulting in residual farsightedness after surgery. If the surgeon feels any further enhancement would be unwise, spectacles or contact lenses may be required. c. Contact lens intolerance. Regardless of success with contact lenses prior to surgery, there is a possibility that the eye will not tolerate contact lenses comfortably after the surgery. d. Increases sensitivity to light. This tends to disappear after a few weeks, or possibly months. It is possible this will remain permanently. e. Decreased vision in artificial or dim light. This may be permanent in some cases. f. Starburst or halo around lights at night. This effect tends to diminish after the first few months, but some element can be permanent. Occasionally, patients have severe enough persisting problems to make them feel insecure driving at night. g. There may be pain, particularly during the first 48 hours. h. Although a double-checking system is in place, the wrong data may be entered into the laser which could result in an undercorrection or overcorrection. By signing below, I agree that: 1. I have received no guarantee as to the success of my particular case. 2. I may be given a sedative at the time of surgery. I agree to arrange for someone to drive me home after my procedure, and to refrain from driving myself until I am comfortable with my vision. 3. As in all surgery, there is the possibility of other complications due to anesthesia, drug reaction, or other factors that involve other parts of the body. These complications rarely occur. 4. I understand that, as well as the surgeon, care will be provided by other health care professionals, including an assistant surgeon, as indicated. Professional personnel, students and product representatives may be present in the operating room during surgery, at the discretion of the surgeon and the surgery center, for education and teaching purposes. 5. If my surgery is recorded, I give permission for its use in research and teaching. 6. The procedure has been explained to me in terms that I can understand. I have had the opportunity to ask all the questions I had regarding the procedure, and they have been answered to my satisfaction. The decision to undergo the laser assisted in-situ keratomileusis (LASIK) procedure has been my own and has been made without duress of any kind. Patient Name Patient Signature Physician Signature Witness Signature Rev. 09/08/05

8 PLEASE WATCH CONSENT VIDEO AND COMPLETE QUESTIONNAIRE. Print your name: : QUESTIONS ON PREPARING FOR LASIK SURGERY VIDEO 2005, Patient Education Concepts, Inc. The following questions cover important information contained in the video presentation. Please circle the answer you feel most correct. If you need more time to answer a question that the video presentation provides, skip that question and return to it when the program is over. Once you have completed the questions, compare your answers to those found at the bottom of the page. 1. TRUE or FALSE: LASIK will permanently change the shape of your cornea. 2. TRUE or FALSE: There are no guarantees as to exactly how well you will see after the procedure. 3. TRUE or FALSE: You may experience side effects such as haze, glare, halos, light sensitivity, and dryness of the eyes that may not go away completely. 4. TRUE or FALSE: All eyes are capable of seeing 20/20 or better. 5. TRUE or FALSE: After the surgery, follow-up visits are not important. 6. TRUE or FALSE: There is the possibility that another operation may be necessary after the initial procedure to obtain the best level of vision correction. 7. TRUE or FALSE: It is possible that you might still need to wear glasses or contacts, or that LASIK could cause loss of vision. 8. TRUE or FALSE: You may experience mild to moderate discomfort for several days after the procedure. 9. TRUE or FALSE: LASIK will eliminate your need for reading glasses when you are over 40 years of age, or presbyopic. 10. TRUE or FALSE: The program that I watched covered all risks, side effects, and complications that could possibly occur either now or in the future with LASIK. Use this space to write any questions or concerns you wish to ask your doctor or a staff member: ANSWERS: 1. TRUE: LASIK will permanently change the shape of your cornea. 2. TRUE: There are no guarantees as to exactly how well you will see after the procedure. 3. TRUE: You may experience side effects such as haze, glare, halos, light sensitivity, and dryness of the eyes that may not go away completely. 4. FALSE: Not all eyes are capable of seeing 20/20 or better. 5. FALSE: After the surgery, follow-up visits are very important. 6. TRUE: There is the possibility that another operation may be necessary after the initial procedure to obtain the best level of vision correction. 7. TRUE: It is possible that you might still need to wear glasses or contacts, or that LASIK could cause loss of vision. 8. TRUE: You may experience mild to moderate discomfort for several days after the procedure. 9. FALSE: LASIK will not eliminate your need for reading glasses when you are over 40 years of age, or presbyopic, unless you have the monovision or blended vision procedure. 10. FALSE: The program that I watched did not cover all risks, side effects, and complications that could possibly occur either now or in the future with LASIK. Signature of patient: : TA S-RS

ALTERNATIVES TO LASIK

ALTERNATIVES TO LASIK EYE PHYSICIANS OF NORTH HOUSTON 845 FM 1960 WEST, SUITE 101, Houston, TX 77090 Office: 281 893 1760 Fax: 281 893 4037 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) INTRODUCTION This information

More information

INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK)

INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) This information and the Patient Information booklet must be reviewed so you can make an informed decision regarding Photorefractive Keratectomy (PRK)

More information

CATARACT AND LASER CENTER, LLC

CATARACT AND LASER CENTER, LLC CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye

More information

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK)

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) Lasik Center 2445 Broadway Quincy, IL 62301 217-222-8800 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) INTRODUCTION This information is being provided to you so that you can make an informed

More information

INFORMED CONSENT FOR LASIK SURGERY

INFORMED CONSENT FOR LASIK SURGERY IMPORTANT: READ EVERY WORD! This information is to help you make an informed decision about having laser assisted in-situ keratomileusis (LASIK) surgery to treat your nearsightedness, farsightedness and/or

More information

INFORMED CONSENT TO HAVE LASIK

INFORMED CONSENT TO HAVE LASIK A Division of Scott & Christie and Associates INFORMED CONSENT TO HAVE LASIK This information is to help you make an informed decision about having Laser Assisted Intrastromal Keratomileusis (LASIK), an

More information

INFORMED CONSENT FOR LASER ASSISTED SUBEPITHELIAL KERATOMILEUSIS (LASEK)/PHOTO-REFRACTIVE KERATECTOMY (PRK)

INFORMED CONSENT FOR LASER ASSISTED SUBEPITHELIAL KERATOMILEUSIS (LASEK)/PHOTO-REFRACTIVE KERATECTOMY (PRK) INFORMED CONSENT FOR LASER ASSISTED SUBEPITHELIAL KERATOMILEUSIS (LASEK)/PHOTO-REFRACTIVE KERATECTOMY (PRK) Please read the following consent form very carefully. Please initial each page where indicated.

More information

IntraLase and LASIK: Risks and Complications

IntraLase and LASIK: Risks and Complications No surgery is without risks and possible complications and LASIK is no different in that respect. At Trusted LASIK Surgeons, we believe patients can minimize these risks by selecting a highly qualified

More information

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) USING INTRALASE TM BLADE-FREE TECHNOLOGY

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) USING INTRALASE TM BLADE-FREE TECHNOLOGY EYE PHYSICIANS OF NORTH HOUSTON 845 FM 1960 WEST, SUITE 101, Houston, TX 77090 Office: 281 893 1760 Fax: 281 893 4037 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) USING INTRALASE TM BLADE-FREE

More information

Eye Associates Custom LASIK With IntraLASIK Correction Of Nearsightedness, Farsightedness, and Astigmatism Using IntraLase TM Technology

Eye Associates Custom LASIK With IntraLASIK Correction Of Nearsightedness, Farsightedness, and Astigmatism Using IntraLase TM Technology Eye Associates Custom LASIK With IntraLASIK Correction Of Nearsightedness, Farsightedness, and Astigmatism Using IntraLase TM Technology INDICATIONS AND PROCEDURE This information is being provided to

More information

INFORMED CONSENT LASER IN SITU KERATOMILEUSIS (LASIK)

INFORMED CONSENT LASER IN SITU KERATOMILEUSIS (LASIK) Edward C. Wade, M. D Christopher D. Allee, O. D. Ting Fang-Suarez, M. D. Jill Autry, O. D. Mark L. Mayo, M. D. Amanda Bachman, O. D. Randall N. Reichle, O. D Julie Ngo, O. D. INFORMED CONSENT LASER IN

More information

Congratulations! You have just joined the thousands of people who are enjoying the benefits of laser vision correction.

Congratulations! You have just joined the thousands of people who are enjoying the benefits of laser vision correction. Dear Valued Patient, Thank you for choosing Shady Grove Ophthalmology for your laser vision correction procedure. Our excellent staff is committed to offering you the highest quality eye care using state

More information

Explanation of the Procedure

Explanation of the Procedure Informed Consent Cataract Surgery with Intraocular Lens Implant Please initial below indicating that you have read and understand each section Introduction The internal lens of the eye can become cloudy

More information

Consent for Bilateral Simultaneous Refractive Surgery

Consent for Bilateral Simultaneous Refractive Surgery Consent for Bilateral Simultaneous Refractive Surgery Please sign and return Patient Copy While many patients choose to have both eyes treated at the same surgical setting, there may be risks associated

More information

TABLE OF CONTENTS: LASER EYE SURGERY CONSENT FORM

TABLE OF CONTENTS: LASER EYE SURGERY CONSENT FORM 1 BoydVision TABLE OF CONTENTS: LASER EYE SURGERY CONSENT FORM Risks and Side Effects... 2 Risks Specific to PRK... 3 Risks Specific to LASIK... 4 Patient Statement of Consent... 5 Consent for Laser Eye

More information

INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK)

INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) 1550 Oak St., Suite 5 1515 Oak St., St Eugene, OR 97401 Eugene, OR 97401 (541) 687-2110 (541) 344-2010 INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) This information is to help you make an informed

More information

Consent for Bilateral Simultaneous Refractive Surgery PRK

Consent for Bilateral Simultaneous Refractive Surgery PRK Consent for Bilateral Simultaneous Refractive Surgery PRK Please sign and return Patient Copy While many patients choose to have both eyes treated at the same surgical setting, there may be risks associated

More information

Associated Eye Surgeons

Associated Eye Surgeons Associated Eye Surgeons 45 Resnik Road, Suite 301 Plymouth, MA 02360 Henry J Kriegstein MD, FACS Board Certified Lois M. Townshend, MD, FRCSC Board Certified Kristin S. Kenney, OD LASIK CONSENT FORM I.

More information

Vision Correction Surgery Patient Information

Vision Correction Surgery Patient Information Vision Correction Surgery Patient Information Anatomy of the eye: The eye is a complex organ composed of many parts, and normal vision requires these parts to work together. When a person looks at an object,

More information

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK)

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) Drs. Fine, Hoffman and Packer, LLC PHYSICIANS AND SURGEONS, EyeMDs OPHTHALMOLOGY I. Howard Fine, M.D. Richard S. Hoffman, M.D. Mark Packer, M.D. 1550 Oak Street, Suite 5 www.finemd.com Eugene, OR 97401-7701

More information

I have read and understood this page. Patient Initials

I have read and understood this page. Patient Initials INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) AND ADVANCE SURFACE ABLATION (ASA) This information and the Patient Information booklet must be reviewed so you can make an informed decision regarding

More information

INFORMED CONSENT FOR LASER REFRACTIVE EYE SURGERY

INFORMED CONSENT FOR LASER REFRACTIVE EYE SURGERY INFORMED CONSENT FOR LASER REFRACTIVE EYE SURGERY INTRODUCTION LASER IN-SITU KERATOMILEUSIS (LASIK) and PHOTOREFRACTIVE KERATECTOMY (PRK) This information is being provided to you so that you can make

More information

LASIK What is LASIK? Am I a good candidate for LASIK? What happens before surgery? How is LASIK done?

LASIK What is LASIK? Am I a good candidate for LASIK? What happens before surgery? How is LASIK done? LASIK What is LASIK? Laser assisted in situ keratomileusis, or LASIK, is an outpatient surgical procedure used to treat myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. With LASIK,

More information

Informed Consent For Photorefractive Keratectomy (PRK)

Informed Consent For Photorefractive Keratectomy (PRK) Edward C. Wade, M. D Christopher D. Allee, O. D. Ting Fang-Suarez, M. D. Jill Autry, O. D. Mark L. Mayo, M. D. Amanda Bachman, O. D. Randall N. Reichle, O. D Julie Ngo, O. D. 6565 West Loop South Suite

More information

LASIK. What is LASIK? Eye Words to Know. Who is a good candidate for LASIK?

LASIK. What is LASIK? Eye Words to Know. Who is a good candidate for LASIK? 2014 2015 LASIK What is LASIK? LASIK (laser in situ keratomileusis) is a type of refractive surgery. This kind of surgery uses a laser to treat vision problems caused by refractive errors. You have a refractive

More information

Informed Consent Enhancement Laser In Situ Keratomileusis (Lasik)

Informed Consent Enhancement Laser In Situ Keratomileusis (Lasik) Edward C. Wade, M. D Christopher D. Allee, O. D. Ting Fang-Suarez, M. D. Jill Autry, O. D. Mark L. Mayo, M. D. Amanda Bachman, O. D. Randall N. Reichle, O. D. Julie Ngo, O. D. 6565 West Loop South Suite

More information

Excimer Laser Eye Surgery

Excimer Laser Eye Surgery Excimer Laser Eye Surgery This booklet contains general information that is not specific to you. If you have any questions after reading this, ask your own physician or health care worker. They know you

More information

Consent for LASIK (Laser In Situ Keratomileusis) Retreatment

Consent for LASIK (Laser In Situ Keratomileusis) Retreatment Consent for LASIK (Laser In Situ Keratomileusis) Retreatment Please read the following consent form very carefully. Please initial at the bottom of each page where indicated. Do not sign this form unless

More information

Refractive errors are caused by an imperfectly shaped eyeball, cornea or lens, and are of three basic types:

Refractive errors are caused by an imperfectly shaped eyeball, cornea or lens, and are of three basic types: Tips on Lasik Eye Surgery If you re tired of wearing glasses or contact lenses, you may be considering Lasik eye surgery one of the newest procedures to correct vision problems. Before you sign up for

More information

Tucson Eye Care, PC. Informed Consent for Cataract Surgery And/Or Implantation of an Intraocular Lens

Tucson Eye Care, PC. Informed Consent for Cataract Surgery And/Or Implantation of an Intraocular Lens Tucson Eye Care, PC Informed Consent for Cataract Surgery And/Or Implantation of an Intraocular Lens INTRODUCTION This information is provided so that you may make an informed decision about having eye

More information

WHAT IS A CATARACT, AND HOW IS IT TREATED?

WHAT IS A CATARACT, AND HOW IS IT TREATED? 4089 TAMIAMI TRAIL NORTH SUITE A103 NAPLES, FL 34103 TELEPHONE (239) 262-2020 FAX (239) 435-1084 DOES THE PATIENT NEED OR WANT A TRANSLATOR, INTERPRETOR OR READER? YES NO TO THE PATIENT: You have the right,

More information

Wang Vision Institute 1801 West End Avenue Nashville, TN 37203 615/321-8881

Wang Vision Institute 1801 West End Avenue Nashville, TN 37203 615/321-8881 Wang Vision Institute 1801 West End Avenue Nashville, TN 37203 615/321-8881 The purpose of this consent for is to educate you on the Phototherapeutic Keratectomy (PTK) and Photorefractive Keratectomy (PRK)

More information

LASEK / PRK Consent Form

LASEK / PRK Consent Form 2305 GENOA BUSINESS PARK DR. SUITE 250, BRIGHTON, MI 48114 (810) 494-2020 (OFFICE), (810) 494-0127 (FAX) LASEK / PRK Consent Form 1. General Information The following information is intended to help you

More information

CONSENT FOR INTRALASIK CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM USING INTRALASE TM TECHNOLOGY BY AMJAD KHOKHAR, M.D.

CONSENT FOR INTRALASIK CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM USING INTRALASE TM TECHNOLOGY BY AMJAD KHOKHAR, M.D. CONSENT FOR INTRALASIK CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM USING INTRALASE TM TECHNOLOGY BY AMJAD KHOKHAR, M.D. INDICATIONS AND PROCEDURE This information is being provided to

More information

790 Montclair Road Suite 100 Birmingham, Alabama 35213 P. 205.592.3911 www.alabamavisioncenter.com

790 Montclair Road Suite 100 Birmingham, Alabama 35213 P. 205.592.3911 www.alabamavisioncenter.com ALABAMA VISION CENTER PRICE M. KLOESS, M.D. ANDREW J. VELAZQUEZ, M.D. 790 Montclair Road Suite 100 Birmingham, Alabama 35213 P. 205.592.3911 www.alabamavisioncenter.com PHOTOREFRACTIVE KERATECTOMY PRE-OPERATIVE

More information

WAKE FOREST BAPTIST HEALTH EYE CENTER. LASIK Consent Form

WAKE FOREST BAPTIST HEALTH EYE CENTER. LASIK Consent Form 1 WAKE FOREST BAPTIST HEALTH EYE CENTER LASIK Consent Form 1. GENERAL INFORMATION The following information is intended to help you make an informed decision about having Laser In-Situ Keratomileusis (LASIK).

More information

Bladeless LASIK and PRK

Bladeless LASIK and PRK Bladeless LASIK and PRK Bladeless LASIK and PRK The specialists at North Shore-LIJ Laser Vision Correction understand how valuable your sight is to you, which is why we use the safest, most advanced technology

More information

LASIK Consent Form. Diagnosis: You have been diagnosed with myopia (nearsightedness) or hyperopia (farsightedness), with or without astigmatism.

LASIK Consent Form. Diagnosis: You have been diagnosed with myopia (nearsightedness) or hyperopia (farsightedness), with or without astigmatism. 2305 GENOA BUSINESS PARK DR. SUITE 250, BRIGHTON, MI 48114 (810) 494-2020 (OFFICE), (810) 494-0127 (FAX) LASIK Consent Form 1. General Information The following information is intended to help you make

More information

We look forward to see you & thanks for trusting us your eyes to us.

We look forward to see you & thanks for trusting us your eyes to us. MEDICATIONS VIGAMOX (OCUFLOX) PURPOSE PREVENTS INFECTION DOSAGE USE 1 DROP 4 TIMES DAILY STARTING 1 DAY PRIOR TO SURGERY VALIUM (Diltiazem 5 mg) AMBIEN (ZOLPIDEM) RESTASIS (if prescribed) Provides relaxation

More information

LASIK or PRK, the identified surgery, is referred to as the Procedure in the following:

LASIK or PRK, the identified surgery, is referred to as the Procedure in the following: At LASIK MD, we strongly believe that you should have all of the necessary information on-hand in order to make an informed decision about your procedure. The content of this consent form is not intended

More information

INFORMED CONSENT FOR PHAKIC IMPLANT SURGERY

INFORMED CONSENT FOR PHAKIC IMPLANT SURGERY INFORMED CONSENT FOR PHAKIC IMPLANT SURGERY INTRODUCTION This information is being provided to you so that you can make an informed decision about having eye surgery to reduce or eliminate your nearsightedness.

More information

TLC LASER EYE CENTERS VISION CORRECTION SURGERY INFORMED CONSENT

TLC LASER EYE CENTERS VISION CORRECTION SURGERY INFORMED CONSENT TLC The Laser Center (Northeast) Inc. TLC Laser Eye Centers (Charlotte) TLC LASER EYE CENTERS VISION CORRECTION SURGERY INFORMED CONSENT Informed Consent. The purpose of this Informed Consent is to help

More information

LASIK PATIENT PACKET

LASIK PATIENT PACKET LASER CENTER LASIK PATIENT PACKET PLEASE BRING BACK WITH YOU THE DAY OF YOUR SURGERY PRE-OPERATIVE INSTRUCTIONS PLEASE REVIEW CAREFULLY WHAT TO EXPECT THE DAY OF YOUR SURGERY POST-OPERATIVE INSTRUCTIONS

More information

LASIK CONTRAINDICATIONS:

LASIK CONTRAINDICATIONS: Left Eye Right Eye INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) FOR THE CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM ** Please don t sign this until you are asked to by our

More information

Shawn R. Klein, MD Klein & Scannapiego MD PA

Shawn R. Klein, MD Klein & Scannapiego MD PA Shawn R. Klein, MD Klein & Scannapiego MD PA Patient Authorization for Laser Vision Correction Surgery 1. General information The following information is intended to help you make an informed decision

More information

Daniel F. Goodman, M.D. 2211 Bush Street, 2nd Floor San Francisco, CA 94115 Phone: 415-474-3333 Fax: 415-474-3939

Daniel F. Goodman, M.D. 2211 Bush Street, 2nd Floor San Francisco, CA 94115 Phone: 415-474-3333 Fax: 415-474-3939 Daniel F. Goodman, M.D. 2211 Bush Street, 2nd Floor San Francisco, CA 94115 Phone: 415-474-3333 Fax: 415-474-3939 INFORMED CONSENT FOR LASIK (LASER IN SITU KERATOMILEUSIS) and PRK (PHOTOREFRACTIVE KERATECTOMY)

More information

On Your Day of Surgery:

On Your Day of Surgery: Please review all instructions for your Lasik/ASA procedure carefully. Call our office (425-899-2020) with any questions you may have before the day of your procedure. If you are a gas permeable or hard

More information

LASIK or PRK, the identified surgery, is referred to as the Procedure in the following.

LASIK or PRK, the identified surgery, is referred to as the Procedure in the following. Consent Form 1. I understand that I am a candidate for LASIK (LASER IN SITU KERATOMILEUSIS) SURGERY, a form of outpatient laser surgery where a surgeon will anesthetize my eye with a topical anesthetic,

More information

ROCKWALL EYE ASSOCIATES

ROCKWALL EYE ASSOCIATES ROCKWALL EYE ASSOCIATES Edward P. Hurst, M.D. Claire Y. Chu, M.D. PHOTO-REFRACTIVE KERATOMILEUSIS (PRK) SECTION 1: GENERAL INFORMATION It is our intention to fully inform you concerning side effects, limitations,

More information

Informed Consent for Refractive Lens Exchange (Clear Lens Extraction)

Informed Consent for Refractive Lens Exchange (Clear Lens Extraction) Informed Consent for Refractive Lens Exchange (Clear Lens Extraction) This form is designed to ensure that you have all the information you need to make a decision about whether or not you wish to undergo

More information

Informed Consent for Refractive Lens Exchange (Clear Lens Replacement)

Informed Consent for Refractive Lens Exchange (Clear Lens Replacement) Mark Packer, M.D. Informed Consent for Refractive Lens Exchange (Clear Lens Replacement) This surgery involves the removal of the natural lens of my eye, even though it is not a cataract. The natural lens

More information

LASER CENTER PRK PATIENT PACKET PLEASE BRING BACK WITH YOU THE DAY OF YOUR SURGERY PRE-OPERATIVE INSTRUCTIONS PLEASE REVIEW CAREFULLY

LASER CENTER PRK PATIENT PACKET PLEASE BRING BACK WITH YOU THE DAY OF YOUR SURGERY PRE-OPERATIVE INSTRUCTIONS PLEASE REVIEW CAREFULLY LASER CENTER PRK PATIENT PACKET PLEASE BRING BACK WITH YOU THE DAY OF YOUR SURGERY PRE-OPERATIVE INSTRUCTIONS PLEASE REVIEW CAREFULLY WHAT TO EXPECT THE DAY OF YOUR SURGERY POST-OPERATIVE INSTRUCTIONS

More information

What is LASIK? The eye and vision errors

What is LASIK? The eye and vision errors What is LASIK? The eye and vision errors 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

More information

Long Island Vision Experts

Long Island Vision Experts GENERAL INFORMATION Long Island Vision Experts 2 Lincoln Avenue, Suite 401 Rockville Centre, NY 11570 (516) 763-4106 INTACS INFORMED CONSENT Intacs (Keratoconus) The following information is intended to

More information

PRK CONTRAINDICATIONS:

PRK CONTRAINDICATIONS: Left Eye Right Eye INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) FOR THE CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM WITH OR WITHOUT MITOMYCIN ** Please don t sign this until

More information

Informed Consent for Cataract Surgery and/or Implantation of an Intraocular Lens (IOL)

Informed Consent for Cataract Surgery and/or Implantation of an Intraocular Lens (IOL) Bruce H. Brumm, MD, PC 6751 North 72 nd Street, Ste 105 Omaha, NE 68122 (402) 572-2020 800-775-5909 www.brummeye.com Informed Consent for Cataract Surgery and/or Implantation of an Intraocular Lens (IOL)

More information

1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690

1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690 1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690 INFORMED CONSENT FOR REFRACTIVE SURGERY INCLUDING LASER IN-SITU KERATOMILEUSIS (LASIK), PHOTOREFRACTIVE KERATECTOMY (PRK), AND ENHANCEMENTS AND

More information

INFORMED CONSENT FOR PHAKIC LENS IMPLANT SURGERY

INFORMED CONSENT FOR PHAKIC LENS IMPLANT SURGERY INTRODUCTION INFORMED CONSENT FOR PHAKIC LENS IMPLANT SURGERY This information is being provided to you so that you can make an informed decision about having eye surgery to reduce or eliminate your nearsightedness.

More information

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) AND LASIK ENHANCEMENTS

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) AND LASIK ENHANCEMENTS 1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) AND LASIK ENHANCEMENTS Please read the following pages carefully and initial and sign

More information

PRK Wavefront Guided idesign Photorefractive Keratectomy

PRK Wavefront Guided idesign Photorefractive Keratectomy PRK Wavefront Guided idesign Photorefractive Keratectomy What is PRK? PRK (photorefractive keratectomy) is the same laser procedure as LASIK. Like LASIK it involves the use of the cool energy of an Excimer

More information

ADDENDUM to the Informed Consent for Cataract Surgery with Intraocular Lens Implant

ADDENDUM to the Informed Consent for Cataract Surgery with Intraocular Lens Implant ADDENDUM to the Informed Consent for Cataract Surgery with Intraocular Lens Implant INTRODUCTION Except for unusual situations, a cataract operation is indicated only when you cannot function satisfactorily

More information

LASIK. Cornea. Iris. Vitreous

LASIK. Cornea. Iris. Vitreous LASIK Introduction LASIK surgery is a procedure that improves vision and can decrease or eliminate the need for eyeglasses or contact lenses. If you and your doctor decide that LASIK surgery is right for

More information

PATIENT CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK)

PATIENT CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) INTRODUCTION: You have been diagnosed with myopia (nearsightedness) or hyperopia (farsightedness) with or without astigmatism, or astigmatism alone. Myopia is a result of light entering the eye and focusing

More information

1801 West End Avenue Suite 1150 Nashville, TN 37203, USA Office: 615.321.8881 Fax: 615.321.8874

1801 West End Avenue Suite 1150 Nashville, TN 37203, USA Office: 615.321.8881 Fax: 615.321.8874 1801 West End Avenue Suite 1150 Nashville, TN 37203, USA Office: 615.321.8881 Fax: 615.321.8874 T he purpose of this consent form is to educate you on the bladeless (Intralase) LASIK procedure. It is not

More information

The LASIK experience WHO CAN HAVE LASIK? SELECTING A SURGEON

The LASIK experience WHO CAN HAVE LASIK? SELECTING A SURGEON The LASIK experience I WHO CAN HAVE LASIK? To be eligible for LASIK you should be at least 21 years of age, have healthy eyes and be in good general health. Your vision should not have deteriorated significantly

More information

UCLA LASER REFRACTIVE CENTER INFORMED CONSENT

UCLA LASER REFRACTIVE CENTER INFORMED CONSENT UCLA LASER REFRACTIVE CENTER INFORMED CONSENT LASER ASSISTED IN SITU KERATOMILEUSIS (LASIK) GENERAL INFORMATION The following information is intended to help you make an informed decision about having

More information

PATIENT CONSENT FORM LASER VISION CORRECTION GENERAL

PATIENT CONSENT FORM LASER VISION CORRECTION GENERAL PATIENT CONSENT FORM LASER VISION CORRECTION GENERAL I. Introduction This Patient Consent Form is provided to help you to make an informed decision about the following types of laser vision correction

More information

Important Information

Important Information Important Information CONDUCTIVE KERATOPLASTY (Also Known as CK) FOR THE CORRECTION OF HYPEROPIA (FARSIGHTEDNESS) AND/OR PRESBYOPIA (NEED FOR READING GLASSES AFTER 40) AND/OR ASTIGMATISM ON-LABEL USE and

More information

ALABAMA VISION CENTER

ALABAMA VISION CENTER ALABAMA VISION CENTER Price M. Kloess, MD Andrew J. Velazquez, MD 7191 Cahaba Valley Road, Suite 203 Birmingham, Alabama 35242 888-841-EYES www.alabamavisioncenter.com LASIK PRE-OPERATIVE INSTRUCTIONS

More information

SLADE AND BAKER VISION CENTER INFORMED CONSENT FOR LASER VISION CORRECTION (LVC)

SLADE AND BAKER VISION CENTER INFORMED CONSENT FOR LASER VISION CORRECTION (LVC) SLADE AND BAKER VISION CENTER INFORMED CONSENT FOR LASER VISION CORRECTION (LVC) PLEASE READ THE FOLLOWING PAGES CAREFULLY AND INITIAL AND SIGN WHERE INDICATED. PLEASE DO NOT SIGN ANY SECTION THAT YOU

More information

LASIK & Refractive Surgery

LASIK & Refractive Surgery LASIK & Refractive Surgery LASIK PRK ICL RLE Monovision + + + For over 30 years, The Eye Institute of Utah has been giving people vision for life... The Eye Institute of Utah was the first medical facility

More information

ShapeVision Lasik + Eyecare KKWF Contest Rules 2012

ShapeVision Lasik + Eyecare KKWF Contest Rules 2012 ShapeVision Lasik + Eyecare KKWF Contest Rules 2012 These contest rules are specific to the above contest conducted by Entercom Seattle LLC d/b/a KKWF, 100.7 The Wolf ( Station ). Except to the extent

More information

Intended Benefits. Who Is Not Eligible For the Procedure? (Intralase Sub-Bowman s Keratomileusis)

Intended Benefits. Who Is Not Eligible For the Procedure? (Intralase Sub-Bowman s Keratomileusis) PATIENT CONSENT FORM Intralase SBK / WGA SBK (Intralase Sub-Bowman s Keratomileusis) Intralase Sub-Bowman s Keratomileusis (SBK) is a term used to describe a Laser Vision Correction procedure where a laser

More information

LASER VISION CORRECTION SURGERY A GUIDE FOR PATIENTS. Professional care for your eye health

LASER VISION CORRECTION SURGERY A GUIDE FOR PATIENTS. Professional care for your eye health LASER VISION CORRECTION SURGERY A GUIDE FOR PATIENTS Professional care for your eye health Contents About Dr John Males... 1 COMMON QUESTIONS How does an eye work?... 2 What is Myopia (short sightedness)...

More information

LASER IN SITU KERATOMILEUSIS (LASIK)

LASER IN SITU KERATOMILEUSIS (LASIK) INFORMED CONSENT FOR EXCIMER LASER LASER IN SITU KERATOMILEUSIS (LASIK) Please read the following pages carefully and initial and sign where indicated. Please do not sign any section that you have not

More information

INFORMED CONSENT FOR PRK SURGERY

INFORMED CONSENT FOR PRK SURGERY INFORMED CONSENT FOR PRK SURGERY Please read the following consent form carefully. Please initial each page where indicated. Do not sign this from unless you read and understand each page. Patient s Name:

More information

INFORMED CONSENT FOR LASIK AND PRK SURGERY

INFORMED CONSENT FOR LASIK AND PRK SURGERY INFORMED CONSENT FOR LASIK AND PRK SURGERY Please read the following very carefully. Please initial each page where indicated. Do not sign this form unless you read and understand each page. Patient s

More information

Dr. Booth received his medical degree from the University of California: San Diego and his bachelor of science from Stanford University.

Dr. Booth received his medical degree from the University of California: San Diego and his bachelor of science from Stanford University. We've developed this handbook to help our patients become better informed about the entire process of laser vision correction. We hope you find it helpful and informative. Dr. Booth received his medical

More information

Clear Advantage Vision Correction Center INFORMED CONSENT FOR PRK

Clear Advantage Vision Correction Center INFORMED CONSENT FOR PRK Clear Advantage Vision Correction Center INFORMED CONSENT FOR PRK PLEASE READ THE FOLLOWING PAGES CAREFULLY AND INITIAL AND SIGN WHERE INDICATED. PLEASE DO NOT SIGN ANY SECTION THAT YOU HAVE NOT READ OR

More information

NOTICE ABOUT REFRACTION

NOTICE ABOUT REFRACTION NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction

More information

Informed Consent for Refractive Lens Exchange (Clear Lens Replacement)

Informed Consent for Refractive Lens Exchange (Clear Lens Replacement) Drs. Fine, Hoffman and Packer, LLC PHYSICIANS AND SURGEONS, EyeMDs OPHTHALMOLOGY I. Howard Fine, M.D. Richard S. Hoffman, M.D. Mark Packer, M.D. 1550 Oak Street, Suite 5 www.finemd.com Eugene, OR 97401-7701

More information

Informed Consent for Cataract Surgery or Clear Lens Extraction with Implantation of an Intraocular Lens

Informed Consent for Cataract Surgery or Clear Lens Extraction with Implantation of an Intraocular Lens Informed Consent for Cataract Surgery or Clear Lens Extraction with Implantation of an Intraocular Lens Please read the following pages carefully, and initial and sign where indicated. Please do not sign

More information

PRESBYLASIK INFORMED CONSENT FOR NEAR VISION MULTIFOCAL LASIK (LASER ASSISTED IN-SITU KERATOMILIEUSIS)

PRESBYLASIK INFORMED CONSENT FOR NEAR VISION MULTIFOCAL LASIK (LASER ASSISTED IN-SITU KERATOMILIEUSIS) !!!!!!! PRESBYLASIK INFORMED CONSENT FOR NEAR VISION MULTIFOCAL LASIK (LASER ASSISTED IN-SITU KERATOMILIEUSIS) The intent of this document is to inform you as to the nature, risks and complications of

More information

THE GUIDE TO REFRACTIVE LENS EXCHANGE SEE CLEARLY.

THE GUIDE TO REFRACTIVE LENS EXCHANGE SEE CLEARLY. THE GUIDE TO REFRACTIVE LENS EXCHANGE SEE CLEARLY. EVERYBODY WANTS TO SEE CLEARLY Many of us take our sight for granted, whether it s forgetting how often we rely on it to guide us through our day-to-day

More information

Risks and Limitations of LASIK Procedure

Risks and Limitations of LASIK Procedure Drs. Fine, Hoffman & Packer, LLC 1550 Oak Street, Suite #5 Eugene, OR 97401 541-687-2110 From Drs. Fine, Hoffman, & Packer Risks and Limitations of LASIK Procedure Infection, serious injury, or even death,

More information

...You Need to know about

...You Need to know about What......You Need to know about LASIK Our Eyes Eyes are the windows to our world. They are so important to us that for many years we have looked for better ways to fix visual problems and improve our

More information

VISION CORRECTION SURGERY PATIENT INFORMATION FORM

VISION CORRECTION SURGERY PATIENT INFORMATION FORM Ramsey Elhosn, MD 2 Executive Park Dr Albany, NY 12203 (518) 487-4200 (518) 708-6896 fax VISION CORRECTION SURGERY PATIENT INFORMATION FORM The purpose of this Vision Correction Surgery Patient Information

More information

Refractive Surgery. Common Refractive Errors

Refractive Surgery. Common Refractive Errors Refractive Surgery Over the last 25 years developments in medical technology and Refractive Surgery allow almost all need for glasses and contact lenses to be eliminated. Currently there are a number of

More information

Alexandria s Guide to LASIK

Alexandria s Guide to LASIK Alexandria s Guide to LASIK A Community Service Project sponsored by: Wallace Laser Center Your Guide To A Successful LASIK Procedure The word LASIK is actually an acronym for Laser Assisted In-Situ Keratomileusis.

More information

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work: Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out

More information

Advanced Eyecare of Orange County Kim Doan, M.D. Eye Physician & Surgeon

Advanced Eyecare of Orange County Kim Doan, M.D. Eye Physician & Surgeon Advanced Eyecare of Orange County Kim Doan, M.D. Eye Physician & Surgeon Patient Information Sheet: Cataract Surgery And/Or Implantation of an Intraocular Lens This information is given to you so that

More information

Our Focus is Your Vision. Image Plus. Laser Eye Centre. LASER VISION CORRECTION Dr. James J. Wiens, M.D., FRCSC Medical Director

Our Focus is Your Vision. Image Plus. Laser Eye Centre. LASER VISION CORRECTION Dr. James J. Wiens, M.D., FRCSC Medical Director Our Focus is Your Vision Image Plus Laser Eye Centre LASER VISION CORRECTION Dr. James J. Wiens, M.D., FRCSC Medical Director Waking and seeing an alarm clock clearly, being able to see while swimming,

More information

Olympia HSA Medical Series. Laser Eye Surgery A COMPLETE GUIDE FOR CANADIANS

Olympia HSA Medical Series. Laser Eye Surgery A COMPLETE GUIDE FOR CANADIANS Olympia HSA Medical Series Laser Eye Surgery A COMPLETE GUIDE FOR CANADIANS 1 Optimal Healthcare and Life Benefits Olympia s All-in-one Benefits Program HEALTH SPENDING ACCOUNTS Optimize your Health Benefits

More information

Kensington Eye Center 4701 Randolph Road, #G-2 Rockville, MD 20852 (301) 881-5701 www.keceyes.com

Kensington Eye Center 4701 Randolph Road, #G-2 Rockville, MD 20852 (301) 881-5701 www.keceyes.com Kensington Eye Center 4701 Randolph Road, #G-2 Rockville, MD 20852 (301) 881-5701 www.keceyes.com Natasha L. Herz, MD INFORMED CONSENT FOR DESCEMET S STRIPPING and AUTOMATED ENDOTHELIAL KERATOPLASTY (DSAEK)

More information

Refractive Surgery Education and Informed Consent

Refractive Surgery Education and Informed Consent Refractive Surgery Education and Informed Consent Tripler Army Medical Center Refractive Surgery Center Warfighter Refractive Eye Surgery Program (WRESP) Goals of this Briefing To explain the Warfighter

More information

CONSENT FORM. Procedure: Descemet s Stripping Automated Endothelial Keratoplasty (DSAEK)

CONSENT FORM. Procedure: Descemet s Stripping Automated Endothelial Keratoplasty (DSAEK) CONSENT FORM Procedure: Descemet s Stripping Automated Endothelial Keratoplasty (DSAEK) Surgeon: Jeffrey W. Liu, M.D. Peninsula Laser Eye Medical Group 1174 Castro Street, Ste. 100 Mountain View, CA 94040

More information

LASER VISION CORRECTION

LASER VISION CORRECTION LASER VISION CORRECTION Laser correction of certain visual problems is the most technologically advanced method available today for reducing your dependence on glasses and contact lenses. The outpatient

More information

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11 PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you

More information

LASIK EPILASIK FEMTOSECOND LASER. Advantages

LASIK EPILASIK FEMTOSECOND LASER. Advantages LASIK EPILASIK FEMTOSECOND LASER Advantages There are many advantages to having laser vision correction. Laser vision correction gives most patients the freedom to enjoy their normal daily activities without

More information

Laser Vision Correction

Laser Vision Correction How will Laser Vision Correction affect my Lifestyle? Your Guide to Laser Vision Correction The Gift of Better Vision A few things to note after your surgery. As you enjoy your new-and-improved eyesight,

More information