California Eye Specialists Medical Group Inc.

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1 California Eye Specialists Name Date of Birth Male/Female last first middle Address street city state zip code Phone # Address home work Social Security # Drivers License Employer company city position phone Parent or Guardian: Name last first middle phone(home & work) Spouse Name: last first middle phone(home & work) Person Whom We May Contact In Case of An Emergency: Name Phone General Physician: Name city phone Whom May We Thank For Referring You To This Office? Medical and/or Vision Insurance company name Please present your insurance card to the front desk Medication Allergies: I have been made aware of and have been provided information regarding the Health Insurance Portability and Accountability Act (HIPAA) and may obtain a copy, of such, upon at my request. Initials I have read the explanation of insurance coverage (see back of sheet) regarding an examination for prescription of eyewear (Refraction) and Understand that there is a separate fee for this service. Should this service not be a covered benefit provided by my Insurance, I understand I will be responsible for the fee. Initials Assignment of Benefits: I hereby assign medical and/or surgical benefits, to which I am entitled, including Medicare, Private Insurance, POS or any other health and/or vision plan to: California Eye specialists Medical Group, Inc. This Assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all uncovered services and any portion my Insurance determines is my responsibility. I hereby authorize said assignee to release all information necessary to secure the payment. SIGNED: DATE:

2 California Eye Specialists Examination for Eyewear (Glasses) An explanation of insurance Coverage Medical insurance covers examinations for the diagnosis and treatment of medical eye problems. It may cover examinations for the prescription of eyewear. Some insurance plans do provide separate vision care benefits through organizations like Vision Service Plan and Medical Eye Services. Should you, at the time of your medical examination, desire the examination for eyewear and do not have the separate vision care insurance or are not covered for this benefit under your medical insurance, we will be happy to provide this service to you for a fee. This fee will be collected at the time of the examination. If you have any questions regarding our eye care, our staff will be happy to assist you. HIPAA PATIENT RIGHTS RESTRICTIONS: You have the right to restrict disclosure of your health information. CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you privately and have no family members present. We will make every effort to honor your reasonable requests. INSPECT AND COPY YOUR INFORMATION: You have the right to read, review and copy your health information. There may be a fee to duplicate your records. AMEND YOUR HEALTH INFORMATION: You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations. DOCUMENTION OF HEALTH INFORMATION: You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations. REQUEST A PAPER COPY OF THIS NOTICE: You have the right to obtain a copy of the Notice of Privacy Practices directly from our office at any time.

3 California Eye Specialists Welcome: Everyone at California Eye Specialists is excited to welcome you into our family of patients. As one of San Gabriel Valley s leading healthcare providers, we look forward to meeting all of your vision care needs now and in the future. We have enclosed for your convenience, an appointment card with our address and phone number as well as the date and time of your appointment. You will also see our Patient Information form. This will allow you the time you need to fill out the information necessary to make your medical health record complete. If we will be billing an insurance for your visit with us, please be sure to bring a copy of your insurance card and any treatment authorization you may have, should it be required. We have also enclosed some eye care information as well as our most current practice newsletter. We hope you will find this information informative and that it reassures your decision of choosing California Eye Specialists. Please visit our website ( for more information or directions to our office. Our physicians and staff take great pride in making your visit as successful and pleasant as possible. Our goal is to consistently provide you with the highest quality of care in a friendly, inviting environment. We look forward to seeing you. Yours in good health, The Team at California Eye Specialists 213 S. Euclid Avenue 150 South Grand Avenue, Ste I 855 West Foothill Boulevard Pasadena, California Glendora, California Monrovia, California

4 Fax Fax Fax California Eye Specialists CATARACTS The human eye is an amazing focusing device utilizing two lenses. The first, our cornea, is our fixed lens, and does about two thirds of the focusing. The second, our lens, is located immediately behind our pupil, and changes shape to focus. The lens is about the size of an M & M candy, and is derived from ectoderm, or skin like tissue, to make it flexible. As we age, the lens elasticity fades, and we begin to need reading glasses mid life. Continued aging results in clouding like the skin wrinkling. This cloudy of the lens is called a cataract. Thus as a cataract forms the vision becomes progressively more blurry and harder to focus, like looking through a cloudy window. The cataract creates more than just blurry vision. Glare, particularly from bright lights like headlights and even the sun, becomes bothersome. This frequently limits the ability to drive at night. Depth perception diminishes making it harder to go down steps, park a car, or perform athletics like golf and tennis as well. Night vision decreases due to a reduction of light getting through the cataract and the resultant decline in contrast sensitivity. And our reading becomes fuzzier, making it harder to see small letters and numbers. Aging of the lens is the most common form of cataract. We can develop cataracts from many other diseases as well as injury, and we can even be born with cataracts. Today, diabetes is a very common cause of earlier cataracts. In younger patients, trauma to the eye is the most common cause. And, eye disease such as glaucoma and retinal problems are associated with earlier cataracts. Everyone who lives into their 60s and 70s develops at least mild cataracts. Early on, the process makes the lens a little harder in addition to cloudy and the eye becomes more nearsighted. So in the early stages, simply changing your glasses prescription will usually improve the sight adequately. This change compensates for the power but does not eliminate the glare and other symptoms, so it is a compromise. At some point, the vision is too blurry to continue the activities the person wishes to do, such as reading, driving or athletic pursuits. We then turn to cataract surgery to restore the vision. Cataract surgery is the most common surgical procedure performed in adults in the United States today. We are fortunate today that the procedure is extremely successful, painless and easy for the patient to go through, and with a return to normal activities in a few days. Cataract surgery accomplishes the removal of the clouded natural lens through a small incision about one-eighth of an inch by phacoemulsification (Phaco), frequently confused with a laser. The surgeon then places an intraocular lens (IOL) inside the eye to restore the vision. The incision usually needs no stitches. The whole procedure takes less than a half-hour and is outpatient. The intraocular lens is critical for restoring the ability to focus. Traditionally until a few years ago, we had single power or monofocal lenses for correcting the vision at one distance. Usually distance was chosen, and glasses were used to correct for reading. We are fortunate to have Multifocal lenses today allow us to see distance and near, and everywhere in between. These Premium lenses restore the vision giving a full range of distances, and most patients only occasionally use glasses afterwards. Cataracts cannot grow back. The capsule holding the IOL may sometimes become wrinkled or cloudy, and a simple laser treatment in the office can restore the clarity. And, we can always develop other eye problems, so it is essential to maintain your habit of regular eye exams to insure your eye health. Talk with your doctor about your cataract, about surgery, and about the various types of implants available, and their effects on your vision after surgery. You and your doctor will develop a plan that pairs you with the best type of implants for your eyes and your vision needs.

5 California Eye Specialists: R. Alan Shelton, MD Olivia Ong, MD Sandy Lee, MD V. Vadrevu, MD David Camara, OD Elizabeth Tsay, OD Minh Le, OD California Eye Specialists Meeting Your Vision Needs: California Eye Specialists is a full service eye care practice with offices in Pasadena, Monrovia and Glendora. We are a leader nationwide in cataract surgery. We have been selected as one of the first 150 practices to offer the new TECNIS Multifocal intra-ocular lens implant, the multifocal to provide reading independent and pupil functions. We perform our surgery at the Eye Surgical Center, customized for Ophthalmic surgery. Dr. Olivia Ong graduated from University of California at Los Angeles in Dr. Ong received her medical degree from UCLA as well. She interned at the West Los Angeles Veterans Affairs Medical Center and completed her residency at Jules Stein Eye Institute in Los Angeles. Dr. Ong also completed a fellowship in glaucoma at the University of California, San Francisco, Beckman Vision Center. She is board certified and a member of the American Academy of Ophthalmology. Dr. Ong provides the most current treatment options. Glaucoma has no symptoms. It is important to have routine eye examinations in order to detect glaucoma early OFFICE LOCATIONS: 213 S. Euclid Ave. Pasadena W. Foothill Blvd. Monrovia S. Grand Ave. Glendora SURGERY CENTER Eye Surgical Center 1809 Verdugo Blvd. Glendale Dr. Alan Shelton, our medical director, is an anterior segment spec+ialist. He received his medical degree in 1982 for Duke University. He is board-certified and a member of the American Academy of Ophthalmology. Dr. Shelton performs over 1600 surgical procedures a year. He is in the top 5 percent of surgeons across the United States in cataract surgery. Dr. Shelton specializes in complex combination cataract, glaucoma, and cornea surgery. Dr. Sandy Lee is our Retina Specialist. She graduated with honors from Wellesley College in Wellesley, Mass. In 1997 Dr. Lee received her medical degree at the University of California San Francisco School of Medicine. She completed her residency at Jules Stein Eye Institute at the UCLA School of Medicine and she is board-certified and a member of the American Academy of Ophthalmology. Dr. Lee provides the newest treatment options for macular degeneration. She is a vitreo retina surgeon using the smallest incision techniques for a less invasive procedure and more rapid recovery. She also performs laser treatment for diabetic retinopathy. At California Eye Specialists, we re committed to state-of-the-art procedures and facilities. Whether you re coming to us for cataract surgery or another procedure, you ll find our modern outpatient surgery center to be welcoming. We understand you may be nervous about your surgery, but know that your peace of mind and comfort are just as important to us as the success of your treatment.

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