ShapeVision Lasik + Eyecare KKWF Contest Rules 2012

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1 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, The Wolf ( Station ). Except to the extent specifically set forth below with respect to this specific contest, the Station s general contest rules apply to this contest as well. A copy of these specific contest rules and the Station s general contest rules are available at the Station s studio at 1100 Olive Way, Suite 1650, Seattle, WA during regular business hours (Monday through Friday 8:30am-5:30pm) and on the contest page on the Station s website at To the extent that the general contest rules differ from these rules, these rules will govern and control with respect to this Contest. How to Enter and Win 1. No purchase necessary to enter or win. 2. To enter, text LASIK to anytime from Monday, November 19 th, 2012 at 6:00 A.M. (PST) through Sunday, December 2 nd at 11:59 P.M. (PST) (the Entry Period ). This is a text-in entry contest only. Standard text messaging rates will apply. 3. You may only enter for yourself not for anyone else. Only one entry per phone number will be accepted as a valid entry in this Contest. Any subsequent or duplicate entries from the same phone number will be disqualified by Station without notice to the entrant. 4. On December 5, 2012, one (1) winner will be selected at random from among all entries received ( Potential Winner ). The Potential Winner will be contacted by KKWF by telephone on or about December 5, 2012 at the telephone number used to enter the contest. Station will only be required to leave one message at the number and if no answer or answering machine is reached, Station will not be obligated to attempt any further contact. 5. The Potential Winner will be required to: (1) sign a Station release and statement of eligibility as described in Section 9 below and (2) meet for one or more consultations with Dr. Matthew Sharpe ( Doctor ) at his office in Bellevue on dates and times designated by Doctor. In order to be awarded the Prize in this contest, the Potential Winner must attend such scheduled appointment and consent to any and all required examinations, tests and procedures required by the Doctor and will be required to sign one or more consent and liability release forms. Failure to attend any of these examinations, to submit to any examination, tests or provide truthful information to the Doctor or other doctors selected by the Doctor, or refusal to timely sign the required liability releases and/or consents required will result in disqualification from the contest in Station s sole and absolute discretion. 6. The Grand Prize Winner must be medically and psychologically eligible for the potential surgeries and/or procedures. Accordingly, all participating entrants acknowledge that if he/she is selected as the Potential Winner that he/she will be required to submit to a variety of medical and/or psychological exams in order for such determination to be made. The nature, extent and number of any required exams to determine such eligibility shall be in the Doctor s sole discretion. Prior to the final determination of the Grand Prize Winner, the Doctor will have performed all examinations, questionnaires, and tests necessary in order to make the final determination that a person to be selected as a Potential Winner is eligible for the Grand Prize. The determination of whether a Potential Winner is medically and/or psychologically eligible for the potential Grand Prize shall be determined solely by the Doctor. In the event that a Potential Winner is determined not to be medically or psychologically eligible for the prize procedure, the Doctor will notify KKWF of such fact and such Potential Winner shall be disqualified from winning any prize in this contest and, time permitting (as determined solely by Station in its sole discretion), Station will randomly select another Potential Winner and repeat the process. 7. The Potential Winner is required to sign one or more Release of Liability Agreement and Affidavit of Eligibility (collectively, Releases ) that, among other things: a. relieves KKWF, Entercom Seattle, LLC, Dr.Matthew Sharpe and the facility at which the service or consultation are performed and each of their respective employees, agents, representatives, officers, director

2 and affiliated companies from any and all liability with respect to the receipt and/or use of any of the prizes and participation in the contest, and b. expressly authorizes KKWF and/or Dr. Matthew Sharpe s office to video tape the performance of the procedure and use such video tape (including, without limitation, the Grand Prize Winner s voice and likeness embodied on such video) to promote and advertise the Station and/or Dr. Sharpe s practice worldwide and in perpetuity in any media existing now or hereinafter developed, without any payment of any kind to the Grand Prize Winner. Any Potential Winner or Grand Prize Winner who refuses to sign and return any of the required consents or releases to KKWF or Dr. Sharpe, as instructed, by the deadline communicated to such winner will forfeit any prize in this contest and another Potential Winner may be selected by Station, in its sole discretion. 8. In the event that KKWF or the participating doctors discover that an entrant has lied or misrepresented the truth with respect to any information discussed during the medical consultations or required medical history disclosure documents (if any), DR. Sharpe and/or KKWF reserve the right to immediately disqualify the entrant without any notice. Prize(s) 9. Subject to the requirements, restrictions, availability and limitations described in these contest rules, the one (1) verified grand prize winner (a Potential Winner who is deemed medically and otherwise eligible to receive this prize) in this contest ( Grand prize Winner ) will receive a Bilateral All-laser lasik procedure, valued at $3,600. The Grand Prize is only redeemable by the Grand Prize Winner and only for services rendered in Bellevue WA by Matthew Sharpe MD, at th Ave. NE., Bellevue, WA The scheduling of surgery, or procedures and any necessary preliminary or post appointments will be based on availability and certain blackout periods and expiration dates may apply (but in no event will the expiration date be prior to June 30, 2013). These restrictions are not subject to negotiation. In the event that all services have not been performed by the expiration date because of lack of cooperation or availability of the Grand Prize Winner, then the Grand Prize (in whole or in part) will be forfeited by the Winner as determined by Sponsors. If the Grand Prize (in whole or in part) is forfeited or the grand prize winner is disqualified for any reason, Sponsors are NOT obligated to select an alternative grand prize winner. 11. If the Winner fails to provide at least seven (7) days prior written notice to the Doctor of any cancellation of any scheduled procedure or appointment or if the Grand Prize Winner fails to arrive on or about (within reason under the circumstances of the doctor s other commitments) the scheduled time of arrival at the facility for the scheduled procedure or appointment, Sponsors reserve the right to declare the Grand Prize void and forfeited. In such event, the Grand Prize may not be awarded to an alternate finalist and the Grand Prize Winner will not be entitled to any further prize in this contest. 12. In addition to all other rules, required releases, and restrictions described in or through these contest rules, by entering this contest all entrants are deemed to acknowledge and agree that (1) the decision to undertake any medical, surgical or similar procedure is a serious decision and that there may be significant health risks, including, without limitation, death, and (2) that Sponsors and each of their respective employees, agents, representatives, officers, director and affiliated companies assume no responsibility, risk or liability for any results, conditions or consequences, directly or indirectly arising from any surgical procedures (including, without limitation, any associated exams, appointments, tests, preliminary or follow-up procedures or appointments) associated with this contest. 13. Regardless of the circumstances, there will be no cash alternatives for prizes. No transfer or assignment of the grand prize (or any part thereof) by the grand prize winner to another person is allowed. 14. BY ACCEPTING ANY PRIZE IN THIS CONTEST, THE GRAND PRIZE WINNER ACKNOWLEDGES AND AGREES THAT CERTAIN HEALTH RISKS ARE INHERENT IN ANY PRIZE INVOLVING MEDICAL OR DENTAL PROCEDURES, INCLUDING, WITHOUT LIMITATION, SOME OR ALL OF THE HEALTH RISKS INCLUDED IN THOSE DOCUMENTS ATTACHED HERETO AS ATTACHMENT A. Please note that winner will be required to sign, among other things, one or more of the consent agreements

3 attached hereto as Attachment A (as applicable) as is and failure to do so will result in forfeiture of all or the affected portion of any prize in this contest, as determined by Station and/or Dr. Sharpe in their sole discretion. 15. In the event that Dr. Sharpe elects to offer and/or provide future services to the Grand Prize Winner (including without limitation any firm of a lifetime guarantee or lifetime commitment ), such future services are NOT part of this prize with respect to Station. In no event will Station be liable to Grand Prize Winner for any services from Dr. Sharpe to be provided on or after December 31, 2013 notwithstanding anything to the contrary which may be communicated to the Grand Prize Winner by Dr. Sharpe or his office. This Grand Prize will be deemed fully delivered by Station and received by the Grand Prize Winner upon competition of the initial procedure and traditional follow-up surgical visits, if any, that occur immediately following the procedure. Sponsor(s) 16. The sponsors of this contest are: Entercom Seattle LLC and Sharpe Vision

4 LASIK + EYECARE INFORMED CONSENT

5 THANK YOU FOR TAKING THE TIME TO REVIEW THIS IMPORTANT INFORMATION ABOUT LASER VISION CORRECTION. You will be asked to sign this Informed Consent document on the day of your procedure. Before signing, please read this information carefully and ask any questions you may still have prior to your procedure. Please contact SharpeVision with questions or concerns. SharpeVision th Ave. NE Bellevue, WA

6 INFORMED CONSENT The cornea and the lens of the eye focus light like a camera lens to form an image on the retina. Light first enters the cornea, which provides a majority of the eye s focusing power. The lens inside the eye provides the remainder. Natural degrees of variation in the shape of the eye affect how well we see. Laser vision correction can be used to treat three of the most common focusing problems: myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. Myopia, or nearsightedness, results when the eyeball is too long or the cornea is too steep. Light will focus in front of the retina, causing blurred vision in the distance. Hyperopia, or farsightedness, occurs when the eyeball is too short or the corneal curvature is too flat, causing light to focus behind the retina. Hyperopia, which causes blurred near and far vision, can be confused with presbyopia, an age-related change in vision causing the need for reading glasses. Astigmatism occurs when the eyeball is oblong-shaped, like a football. As a result, light cannot be focused properly, blurring vision at all distances. Astigmatism is often present along with myopia and hyperopia. Presbyopia occurs in our mid-40s as the natural lens loses its flexibility to change the eye s focus from distance to near. Laser vision correction does not change this process. Whether it is glasses with bifocals, contacts with reading glasses, or laser vision correction with reading glasses, the loss of flexibility is the problem, and you will need some help for this problem. Monovision is enjoyed by millions of people and is an option that will be thoroughly discussed and demonstrated at your exam. With monovision, the focus of one eye, usually your dominant eye, is set for perfect distance vision, while your other eye is set for near vision. It is not an option for everyone and can sometimes be reversed after a period of adaptation, should you decide that it is not working for you. The term refractive surgery describes various procedures that modify the refractive error of the eye. Most of these procedures involve altering the corneal shape. In performing laser vision correction procedures, the surgeon controls a computerguided excimer laser that emits cool pulses of ultraviolet light to remove a small amount of tissue at the front of the eye. The procedures are designed to reshape the corneal curvature, which allows light to focus on the retina and improve your vision. Excimer laser energy is absorbed very superficially, so the other eye structures such as the iris, lens, and retina remain undisturbed. The most common laser vision correction procedures are LASIK and PRK. Laser Assisted in Situ Keratomileusis (LASIK) uses a femtosecond laser, or a microkeratome, to create a corneal flap on the surface of the eye. After opening the flap to expose the tissue below the cornea s surface, the excimer laser is used to remove thin layers from the cornea to reshape it. The flap is then returned to its original position. Photorefractive Keratectomy (PRK) uses the same excimer laser, which produces a beam of light to remove thin layers from the cornea to reshape it after the surface layer (corneal epithelium) has been removed. The surface layer typically grows back over 4-5 days. Laser vision correction permanently removes tissue from your cornea. Although LASIK and PRK are permanent operations to the cornea, additional laser treatments are usually possible to correct small residual prescriptions that occur in a small percentage of patients. There are a number of contraindications or relative contraindications for laser vision correction. These include patients with unstable refractions, certain abnormalities of the cornea, abnormal corneal topography, insufficient corneal thickness, irregular astigmatism, a visually significant cataract, uncontrolled glaucoma, uncontrolled external disease, uncontrolled connective tissue or autoimmune disease, unrealistic expectations, certain ocular anatomical issues, 4

7 functional monocularity, overly steep or flat corneas, dry eye syndrome, pregnancy or lactation, poorly controlled diabetes, prior incisional or lamellar keratorefractive surgery, and significant occupational or recreational risk, among other factors. With the recommendation of your doctor, the laser can be used to perform laser vision correction outside of the FDA guidelines, including when treatment may otherwise be contraindicated. If you are choosing to have laser vision correction and have a prescription outside of the approved ranges or have contraindications, you understand and accept the risks of doing so. These procedures are elective and involve complex surgery to the eye. Not everyone is a good candidate for laser vision correction. The ideal candidate is over 18 years old, has had stable vision for at least six months, has a healthy cornea, has refractive errors within the treatable range, does not have a disease or condition that could impair the procedure or healing process, understands that the goal of the procedure is to improve vision and reduce dependence on glasses and contact lenses, and has been fully educated about the procedure and its risks and benefits. Please let Dr. Sharpe or his team know if you still have questions that have not been answered. Prior to moving forward with the decision to have surgery, it is important that you fully understand the risks of these treatments and have the information you need to fully assess these risks and any alternative treatments you may want to consider. Through the information we make available to you our brochures and videos, website, and discussion with Dr. Sharpe and his team it is our hope and expectation that you feel educated and informed about the safety and efficacy of the procedure. We realize this is an important decision for you, and we want you to feel comfortable and informed in making it. By signing, you agree and acknowledge that you have watched the informational video, you have had an opportunity to have all your questions answered, and that you specifically understand that: Benefits and outcome cannot be guaranteed. Although our goal is to reduce or even eliminate myopia or hyperopia, with or without astigmatism, your outcome cannot be guaranteed. It is possible that your treatment could result in over or under response, requiring continued use of glasses or contact lenses following surgery; an induction or change of an astigmatism; infection, inflammation or haze that could result in permanently decreased vision; and a loss of your best-corrected visual acuity, including the development of irregular corneal shape. It is also possible that you may not be able to have an enhancement procedure in the future. Refractive surgery is not right for you if you want a guarantee of a perfect outcome. Night glare or increased light sensitivity may result. You may experience a starburst or halo effect around lights at nighttime. If you have high myopia, high astigmatism, or dry eyes, you may be more likely to have night-glare issues. Your overall vision at night may not be as sharp as during the day, and you may experience increased sensitivity to light or glare. You may experience haze or corneal cloudiness, which could become evident in the weeks or months following surgery. PRK has a small risk of haze, which is difficult to treat and may result in loss of best-corrected visual acuity and permanent loss of visual sharpness or clarity. Measures will be taken and medications employed to minimize this risk. 6

8 Dry eyes occurs in most people, but varies widely in duration and intensity. You may experience dry eyes following the procedure, causing mild to severe irritation, discomfort, and blurring of vision. If this occurs, you may need to use certain over-the-counter or prescription medication for an indefinite period of time. Post-menopausal women or patients taking certain medications may be at a higher risk of developing dry eyes. Reading glasses may be required. If you are over 40 years of age and decide to have laser vision correction to correct both eyes for distance vision, you may need reading glasses to see objects at approximately three feet or closer. If you are over 40 years, be sure you understand monovision, which corrects one eye for near vision. Corneal weakening may occur. You may develop a rare corneal condition called corneal ectasia, in which the cornea progressively thins and blurs vision. This condition can be difficult to diagnose in its early stages, and laser vision correction may accelerate this degeneration. LASIK patients are at higher risk for developing ectasia than patients who have PRK. Complications of the surgery itself may occur. You may develop a corneal flap complication that could require your procedure be postponed either temporarily or indefinitely. If you develop certain complications with your corneal flap following surgery including, but not limited to, striae (wrinkles), epithelial ingrowth, or inflammation your flap may need to be re-lifted, which can cause additional complications. The equipment used in the procedure may also malfunction. Depending on the circumstances, these complications could cause loss of vision. Following PRK laser vision correction, an anti-cancer medication known as Mitomycin-C (MMC) is applied to the cornea as an off-label use (not specifically approved by the FDA) to reduce the potential for corneal haze. Other complications. As with all surgery, there is a possibility you may experience other complications, including, but not limited to, those due to drug reactions, among others. Failure to provide the staff of health care professionals with your complete medical history, including drug allergies and pre-existing medical and eye conditions, may increase your risk of developing complications. Contraindications. You understand that there are situations in which treatment may be contraindicated, including, but not limited to: unstable refraction, abnormalities of the cornea, uncontrolled disease, history of severe or active eye infection, glaucoma, certain systemic medications, poorly controlled diabetes, pregnancy or lactation, and prior incisional or lamellar keratorefractive surgery. It is important that you provide your complete medical history. You are aware of the alternatives to laser vision correction, which include eyeglasses, contact lenses, and other types of refractive surgery or refractive lens implants. You have read this informed consent thoroughly, have watched the informational video, have received a notice of privacy practices, and have had ample opportunity to discuss these terms and have all your questions answered. You have been provided an opportunity to learn about and meet with Dr. Matthew Sharpe, and you recognize that the procedure will be performed by Dr. Sharpe himself, a board-certified ophthalmologist. 8

9 PRESBYOPIA + MONOVISION As part of the normal aging process, the lens of our eye becomes less flexible, which is the reason why reading glasses, bifocals, or removing distance glasses become necessary to see up close in our mid-40s and beyond. Monovision is one treatment for presbyopia. While laser vision correction cannot currently cure presbyopia, it can make it possible for these patients to see close without reading glasses. Monovision is a process of providing both distance and near vision by focusing one eye on distant objects and one eye on near objects. It can be more difficult to see at night with monovision. You understand that adapting to monovision can take 12 weeks or more and that it may never occur to your total satisfaction. Monovision can sometimes be reversed if you decide that it doesn t work for you. PATIENT S STATEMENT OF ACCEPTANCE AND UNDERSTANDING The details of the recommended procedure have been explained to me by Dr. Sharpe and his staff. All of my questions have been answered to my satisfaction. I therefore consent to: On my: LASIK PRK Right eye Left eye Both eyes I DO want monovision. Right Eye: Distance Near Left Eye: Distance Near I DO NOT want monovision. CATARACTS Nearly everyone develops cataracts with age. This is still true after laser vision correction. Some patients may have mild cataracts at the time of laser vision correction that are not yet visually significant. If this is true for you, laser vision correction will not prevent this condition from worsening as your cataracts advance. If the cataracts advance to the point laser vision correction cannot help correct your vision, you will need standard cataract management practices. Patient Signature Printed Name Witness Signature Surgeon Date Date Date I DO have early cataracts. I DO NOT have early cataracts. 10

10 SharpeVision th Ave. NE Bellevue, WA

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