Patient Information. How did you hear about Kugler Vision? Date. Dr Mr Mrs Ms Miss (clrcle one) Male Female (circle one)

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1 Patient Information Date Dr Mr Mrs Ms Miss (clrcle one) Male Female (circle one) First Name Middle Name Last Name Suffix Nickname Date of Birth SSN Street Address City State Zip Code Home Phone Work Phone Other / Cell Phone Address Employer Occupation Spouse / Parent Spouse s / Parent s Employer Emergency Contact Emergency Phone Number Name of Primary Insurance Name of Secondary Insurance Insurance Number How did you hear about Kugler Vision? Referred by a medical doctor Name of medical doctor : Referred by an eye doctor Name of eye doctor : Existing patient Name of patient : Radio Station : Word of mouth Web Other / Don t Know

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3 ! Pre-Surgical Cataract Patient Questionnaire Patient Name: Date of Birth: Eye being evaluated: Right Left VISUAL FUNCTIONING Do you have difficulty, even with glasses, with the following activities: Yes No i. Reading small print, such as labels on medicine bottles, telephone books or food labels? ii. Reading a book or newspaper? iii. Reading a large print book, large print newspaper or large numbers on a telephone? iv. Recognizing people when they are close to you? v. Seeing steps, stairs or curbs? vi. Reading traffic signs, street signs or store signs? vii. Doing fine handwork like sewing, knitting, crocheting or carpentry? viii. Writing checks or filling out forms? ix. Playing games such as bingo, dominos or card games? x. Taking part in sports like bowling, handball, tennis or golf? xi. Cooking? xii. Watching television? Please continue on the back side of the form!1

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5 Lance Kugler, MD An Omaha native, Dr. Kugler earned his undergraduate degree from DePauw University in Greencastle, Indiana, where he graduated magna cum laude with a degree in Computer Science. He then went on to earn his MD from Case Western Reserve University School of Medicine in Cleveland, Ohio. He returned to Omaha for residency training in ophthalmology at the University of Nebraska Medical Center. Following residency training, Dr. Kugler entered private practice. After practicing ophthalmology in the Omaha area for four years, Dr. Kugler saw that Nebraska was in need of a surgeon with advanced training in state of the art LASIK and cataract surgery. Building on his background in computer science, Dr. Kugler and his family moved to Nashville, Tennessee where he completed a prestigious fellowship in Cornea and Refractive Surgery under the guidance of Ming Wang, MD, PhD, a world renowned ophthalmologist with a PhD in laser physics. Dr. Kugler performed over 1300 refractive surgical procedures during his fellowship, by far the most of any fellow in the country, and became an expert in managing complicated LASIK cases and helping patients who had suffered from LASIK complications elsewhere. Upon returning to Omaha, Dr. Kugler purchased Dr. Schlichtemeier s practice, bringing the latest state of the art LASIK and cataract surgery technology to Nebraska. Dr. Kugler also serves as Director of Refractive Surgery for the University of Nebraska Medical Center, where he is in charge of resident education and research programs to advance the field of refractive surgery. Dr. Kugler has authored several peer reviewed journal articles and textbook chapters, and presents at national meetings. He serves as the Principal Investigator for two FDA clinical trials, one that is investigating a new surgical device to reduce patients' need for reading glasses, and one that is investigating a new surgical procedure to treat keratoconus, a degenerative corneal disease. He is an international consultant for corneal topography scans, computer generated maps of the surface of the eye, and also serves as a peer reviewer for several scientific journals. He was invited to join as one of the top 1% refractive surgeons in the country. Dr. Kugler is active at the national level through his involvement in the American Academy of Ophthalmology. He is a member of the YO (Young Ophthalmologist) YO info subcommittee and is a graduate of the prestigious AAO Leadership Development Program. Dr. Kugler is board certified by the American Board of Ophthalmology. Dr. Kugler lives with his wife Traci and their five children. Dr. Kugler is an expert in the following: Laser Surgery: Bladeless LASIK surgery PRK (advanced surface ablation) Intralase Laser assisted Intacs ring segment implantation for the treatment of keratoconus Intralase laser assisted Corneal Transplantation Treatment and management of post LASIK complications Cataract and Lens Surgery: Implantable Collamer Lenses (ICL) for the treatment of severe near sightedness in eyes that have not been a candidate for LASIK before Cataract and lens implant surgery using advanced lifestyle implantable lens technology to reduce the need for glasses Conductive Keratoplasty for the treatment of presbyopia (the need for reading glasses after age 40) Scleral Spacing Procedure (SSP) for the treatment of presbyopia

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