LASIK EXAM INFORMATION LASIK PROCEDURE INFORMATION

Transcription

1 LASIK EXAM INFORMATION Thnk you for choosing Cstlemn Eye Center for your LASIK evlution. Wht to expect: 1. Your consulttion with our ophthlmologist will lst pproximtely 2 hours. 2. To perform complete eye exmintion for LASIK, your eyes will be dilted. This cuses light sensitivity nd blurry ner vision nd my lst for 24 hours. 3. If you re concerned bout driving while dilted, plese hve driver ccompny you. 4. Bring your current eyeglsses (or prescription) with you, s well s sunglsses--we cn provide sunglsses if needed. 5. LASIK fees vry bsed on your level of correction nd will be determined during your ppointment. CONTACT LENS PATIENTS IMPORTANT!! If Your Contcts Are: Soft Contcts Do not wer contcts for 3 dys prior to exm Hrd Contcts/Rigid/Gs Permeble Do not wer contcts for 3 full weeks prior to exm LASIK PROCEDURE INFORMATION You nd your doctor decide together which LASIK option is best for you. There re 2 steps involved in LASIK procedures: o Step 1 is Flp Cretion nd cn be done by blde or Lser (ilasik). o Step 2 is reshping your corne nd cn be done using Stndrd tretment (bsed on your eye exm) or CustomVue Advnced tretment (uses computerized mp of your eye for tretment). The preferred method is CustomVue Advnced LASIK (ilasik) due to precision results nd less risk of flp complictions. o The vst mjority of ilasik ptients see 20/20 or even better! You re wke during the LASIK procedure, but you will be given mild sedtive pill to help you relx. Your eyes will be numbed with drops, nd side from little pressure, you most likely won't feel ny pin. Both eyes re treted t the sme visit nd most ptients return to work the next dy. The LASIK procedure tkes less thn 15 minutes. Appointment Dte: Time: Eurek Rd Southgte MI Est Long Lke Rd Troy MI u:ceclasik:procedurefeeinfo

2 Demogrphics Form PATIENT NAME HOME PHONE# WORK PHONE# CELL PHONE# ADDRESS CITY STATE ZIP SEX AGE BIRTH DATE MARITAL STATUS S M D W MI SOCIAL SECURITY NUMBER NOTE: The informtion below is reporting requirement of the government Ptient Protection nd Affordble Cre Act We re obligted to obtin this informtion from our ptients. Rce White Americn Indin or Alsk Ntive Asin Blck or Africn Amer Ntive Hwiin or Other Pcific Islnder EMPLOYER SPOUSE NAME Ethnicity: Hispnic Not Hispnic Lnguge Preference: English Other OCCUPATION SPOUSE S EMPLOYER EMERGENCY CONTACT: ( For office use only: remember to dd to P Prtner) NAME: Primry: PHONE: MEDICAL INSURANCE INFORMATION Subscriber Nme/Birthdte: Secondry: Tertiry: Subscriber Nme/Birthdte: Subscriber Nme/Birthdte: Primry VISION INSURANCE Secondry How were you referred to us? Ptient/Fmily Google Internet Insurnce Loction Fmily Doctor Other Fmily Doctor: Phrmcy Nme: If referred by Doctor plese dd informtion here: Nme: Address: City: Phone: Address: City: Zip: Phone: Address: City: Zip: Phone:

3 Medicl History Questionnire Ptient Nme: Dte of Birth: Allergies (drug, food or substnce) & Rection Severity mild / moderte / severe mild / moderte / severe Pst Oculr History: (Plese mrk ll tht pply) No History of Eye Disese Ctrcts Hyperopi (Fr sighted) Myopi (Ner sighted) Amblyopi (Lzy eye) Dibetic Retinopthy Iritis Optic Neuritis Aphki Dry Eyes Kertoconus Retinl Detchment Astigmtism Glucom Mculr Degenertion Other Eye Surgeries: (Plese mrk ll tht pply & list dtes) Glucom lser surgery No Prior Eye Surgery Foreign Body Removl Punctl Plugs Trbeculectomy Blephroplsty Retinl Lser Surgery RK (Glucom surgery) Ctrct Surgery LASIK Strbismus Surgery Vitrectomy/Retin Surgery Cornel Trnsplnt PRK (eye muscle surgery) Other Current Eye Drops (if ny): (Plese list) Medicl Illnesses (if yes, indicte # of yers): Overll Helthy Congestive Hert Filure Heptitis A B or C Lung Disese Anemi COPD High Blood Pressure yrs Lupus Arthritis Dibetes yrs High Cholesterol Migrine Arrhythmi Eczem Grves Disese Polymylgi Asthm Fibromylgi Kidney Disese Psychitric Disorder Bleeding Disorder Hedche Kidney Stones Skin Cncer Cncer Hering Loss Liver Disese Stroke Thyroid Disese AIDS/HIV positive Lupus Mult. Sclerosis(MS) Herpes/Shingles Sjogrens Rheumtoid Arthritis Histoplsmosis Toxoplsmosis Insulin? Yes No Plquenil for Rheumtoid Arthritis? Yes No Other Generl Surgeries / Opertions: (Plese list ll & dtes) Plese continue on the bck side of this pge Current Medictions: (Plese list) Pge 2

4 Fmily History (Mother, Fther, Siblings, Grndprents): Dibetes Stroke Blindness Mculr Degenertion Arthritis Cncer TB Ctrcts Retinl Disese Lzy Eye Hert Disese Kidney Disese Glucom High Blood Pressure Other Socil History: (Plese mrk ll tht pply) Smoking: current every dy smoker current some dy smoker former smoker never smoked Alcohol Use: Yes No If yes how much nd how often? Drug Use: Yes No If yes wht nd how often? Review of Systems: (Plese mrk ll tht pply): Eyes Previous Surgery Contct Lens Pin Double Vision Glucom Ctrcts Mculr Degenertion Dry Eyes Flshes Floters Respirtory Cough Congestion Wheezing Asthm Gstrointestinl Hertburn Nuse / Vomiting Jundice / Heptitus Blood / Lymphnodes Esy Bruising Gums Bleed Esy Prolonged Bleeding Hevy Aspirin Use MusculoSkeletl Stiffness Arthritis Joint Pin / Swelling Er, Nose, nd Throt Hrd of Hering Ringing in Ers Vertigo Crdiovsculr Chest Pin Dizziness Finting Spells Shortness of Breth Irregulr Hert Bet Difficulty Lying Flt Constitutionl Ftigue / Wekness Fever Weight Gin / Loss Genito-Urinry Pin / Difficulty Blood in Urine History of Kidney Stones History of STD s Psychitric Anxiety / Depression Mood Swings Difficulty Sleeping Endocrine Incresed Thirst Incresed Hunger Incresed Urintion Incresed Sweting Fingernil Chnges Skin Rsh / Sores Lesions Hives / Eczem Neurologicl Seizures Wekness / Prlysis Numbness Tremors Immunologic Hives Itching Runny Nose Sinus Pressure Pge 3

5 Cstlemn Eye Center Directions to Our Offices Southgte Office Eurek Rod, Southgte, MI, (734) Directions: From Telegrph (US 24) North/South: Tke Telegrph to Eurek Rod est. Get in left lne to mke the turn-round to go west on Eurek Rod. Tke Eurek Rod Est turn Left t Eurek Rod (which is just before Fort St. cross the street from Arby's resturnt). Coming from the North: Tke I-75 to the Eurek Rod exit (Exit #36). Turn left on Eurek est. Tke Eurek Rod Est turn Left t Eurek Rod (which is just before Fort St. cross the street from Arby's resturnt). Coming from the South: Tke I-75 to the Eurek Rod exit (Exit #36). Turn right on Eurek. Tke Eurek Rod Est turn Left t Eurek Rod (which is just before Fort St. cross the street from Arby's resturnt). From I-275 North/South: Tke I-275 to Eurek Rod (Exit #15). Turn right/left (est) on Eurek Rod nd go pproximtely 15 miles. Turn Left t Eurek Rod (which is just before Fort St. cross the street from Arby's resturnt). Troy Office Address: 113 Est Long Lke Rod, Troy, MI Directions: From: I-75 North/South Tke the Big Bever rod exit nd trvel est to Livernois. On Livernois, trvel north to E. Long Lke Rod. We re locted on the north est corner of the E. Long Lke/Livernois intersection. Look for the Sunset Plz/CVS where Cstlemn Eye Center is prominently displyed on our office. From I-75 North/South (Alternte Route): Tke Rochester Rd. North to E. Long Lke. Sty in the right lne becuse you will hve to turn right t E. Long Lke, mke Michign left nd go west on E. Long Lke Rod. Look for the Sunset Plz/CVS on the right just before the ctul Livernois/E. Long Lke intersection. Cstlemn Eye Center is prominently displyed on our office. lmgeyecenter(rev10.09)

6 Am I Cndidte? Cstlemn Eye Center Chnging Lives Through Vision Perhps the gretest news bout ilasik is tht the mjority of people with nersightedness, frsightedness s well s stigmtism re cndidtes for this stte-of-the-rt vision correction procedure. With the use of bldeless flp cretor, nd the wide rnge of vision imperfections tht the FDA-pproved tretment lser cn correct, more people thn ever before re excellent cndidtes for lser vision correction. If you nswer true to ll the following criteri, it s time for you to schedule n evlution with your ilasik surgeon tody! *FREE LASIK Consulttion *0% Finncing for 2 Yers *All Inclusive Pricing-No Hidden Fees *Vitls Ptient's Choice Awrd 2012 *Over 9000 Procedures Performed *LASIK Discount Progrm for Vision Plns *Over 40 Yers in Prctice The Future of Lser Vision Correction is Here I m in overll good helth. I hve hd stble eye prescription for t lest one yer. I hve no existing eye diseses. I m t lest 21 yers old. I wnt to chnge my life nd lifestyle with freedom from glsses nd contcts. Cstlemn Eye Center Eurek Rod Southgte, MI PH: F: Cstlemn Eye Center Chnging Lives Through Vision

7 Truly Customized All-Lser LASIK If you ve been witing for the best in vision correction technology, your wit is over. All-lser ilasik combines the very ltest of three FDA-pproved technologies to provide truly customized LASIK procedure tilored specificlly for your vision imperfections. Although surgeons hve been performing LASIK procedures with gret success over the pst decde, never before hs lser vision correction been ble to ddress ech individul s vision needs with such precision nd deliver such gret results. ilasik in Action Every process in ilasik is customized for you, nd ids the surgeon in getting the best possible results for your lser vision correction procedure. There re three min steps to the ilasik procedure. Step 1: WveScn Mp The first step in ilasik is the preprtion of the WveScn 3-D mp. Through series of tests, this tool mps out ll the imperfections in your vision so your personlized vision correction pln cn be formulted for the Advnced CustomVue vision correction lser. Step 2: Intrlse Lser Although complictions re rre, in conventionl LASIK the mjority occur during the cretion of the flp with the microkertome blde. The Intrlse Lser used in ilasik elimintes these types of complictions. The flp, creted with the Intrlse Lser, is thinner, more precise flp tht llows for fster heling of the corne. Step 3: Advnced CustomVue lser vision correction The lst step in creting vivid nd cler vision for you is the custom lser tretment on your corne. The WveScn mp provides the surgeon nd the lser s computer the informtion needed to reshpe your corne for your best vision possible. The cool bem of light trets the corne pinlessly nd precisely, in just mtter of seconds. Wht s The Next Step? If you ve been thinking bout vision correction for while now but hven t been ble to commit, or you ve been told in the pst you weren t cndidte, now is the time to re-evlute. If your concerns re over results, ilasik ddresses those concerns for most people. In clinicl studies, 100% of nersighted ptients nd 95% of ll prticipting ptients could pss driver s test without glsses or contcts one yer lter. In ddition, 98% of ptients with mild-to-moderte nersightedness obtined 20/20 vision or better. If you weren t cndidte for conventionl LASIK becuse you required tretment outside the pproved prmeters, or your cornes were too thin, you my now be cndidte for ilasik. ilasik is opening the doors to future of better vision for mny people who were not previously eligible. If you hve questions bout ffordbility, most surgeons nd LASIK centers hve prtnered with 3rd prty finncing compnies to offer ffordble monthly pyments. Your next step is to schedule n evlution or consulttion with n ilasik surgeon to discuss your concerns in detil, confirm you re cndidte nd then schedule your surgery dte. It s s simple s tht! You ll be enjoying your new vision before you know it nd you ll wonder why you wited so long. New NASA guidelines specify tht only ilasik my be performed on its stronuts using precise mesurement nd wvefront-guided lsers #35739 Doctordirect

8 Snigdh Singh, M.D. Tiffny Humes, O.D. Jmes R. Vlice, M.D. John M. Rmocki, M.D. Why Choose Cstlemn Eye Center for your LASIK procedure? 1. We hve our own dedicted Stte of the Art LASIK Operting Suite in our Troy office where we personlly oversee the mintennce nd sfety of the equipment. There re some lsers tht re trnsported from office to office on dily bsis. It is importnt to mintin temperture nd humidity t ll times for the lser to function properly. 2. We hve performed over 9,000 Lser Vision Correction Procedures nd hve been in prctice for over 40 yers. Dr. Singh received Vitls ( leding physicin review site) Top 10 Doctor Awrd 2014 nd the Ptient s Choice Awrd for 2012 nd 2013, long with 4 out of 4 Strs Rting. 3. We offer ALL LASER LASIK (ilasik). The LASIK flp is creted with LASER, not blde. Eliminting the blde, gives you sfer, more precise LASIK. In fct, ll brnches of the U.S. Militry only recommend ilasik technology for their servicemen nd women. 4. We offer FREE Consulttions nd No money down, ZERO INTEREST FINANCING for 2 Yers through Cre Credit. 5. All inclusive pricing, no hidden fees. Our fees include pre-op testing, surgery nd post-op cre for one yer. Owning our lser enbles us to offer very competitive pricing. 6. Our surgeons re ll bord certified, licensed ophthlmologists, ech with over 14 yers experience. 7. Our VISX certified, surgicl support stff ech hve over 14 yers experience ssisting doctors in thousnds of LASIK surgery procedures. 8. We use the VISX S4 Lser nd CustomVue Wvescn Technology. The Wvescn produces detiled mp of the eye, much like fingerprint, nd trnsltes these digitl tretment instructions directly to the VISX S4 Lser. The CustomVue procedure then tilors distinct correction for ech eye, which corrects unique imperfections, providing new level of ccurcy nd high definition vision. Not ll lsers hve this cpbility. 9. All pre-op nd post-op cre is provided by your surgeon, not ncillry stff. 10. We re conservtive with our recommendtions. We won t perform the LASIK procedure if we don t think you will chieve excellent results. 11. We offer mny discount progrms. Visit our website t for more informtion. 12. Our surgery center ws nmed one of the 100 Best Plces to Work in Helthcre by Becker s ASC Review Eurek Rd Southgte MI Tel: (734) Fx: (734) E. Long Lke Rd Troy, MI Tel: (248) Fx: (248)

9 With CreCredit... Strt cre immeditely Py over time with low monthly pyments For yourself nd your fmily Two Types of Promotionl Plns Avilble: No Interest if Pid in Full within 6, 12 or 18 Months On purchses with your CreCredit crd. Not ll promotionl plns re vilble in ll offices. Interest will be chrged to your ccount from the purchse dte if the promotionl blnce, including optionl chrges, is not pid in full within 6, 12 or 18 months or if you mke lte pyment. Minimum Monthly Pyments Required. or 14.90% APR & Fixed Minimum Monthly Pyments for 24, 36, 48 or 60 Months On Purchses of $1,000 or more (24, 36 or 48 months) or $2,500 or more (60 months) with your CreCredit crd. Accounts t Penlty APR ineligible for reduced APR. Fixed Minimum Monthly Pyments Required. Penlty APR my pply if you mke lte pyment. (See pge 11 for detils) Step 1 Plese follow these guidelines when completing your ppliction: Plese hve vilble two forms of ID tht cn be verified: one primry ID nd one secondry ID or two primry IDs. If using co-pplicnt, the co-pplicnt must be present nd lso provide two forms of ID. Acceptble primry ID re Stte issued driver s license (preferred), government issued ID, Non- Driver Stte issued ID, Pssport, Militry ID or Government issued Green/Resident Alien crd. Acceptble secondry IDs re Vis, MsterCrd, Americn Express, Discover, deprtment store or n oil compny credit crd with n expirtion dte. Plese include ll forms of income from ll full nd prt-time jobs, bonuses, commissions, nd investments. You need only include child support, limony, or seprte mintennce income if you wish this income to be considered in your ppliction. Plese note tht you must reside in the United Sttes nd be 18 yers or older to pply. Step 2 Plese complete the rest of the ppliction on the reverse side Revision Dte: 11/15/2010 DATE OF PRINTING: 9/10

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11 Interest Rtes nd Interest Chrges Annul Percentge Rte (APR) for Purchses nd Blnce Trnsfers 26.99% GE MONEY BANK CREDIT CARD AGREEMENT Keep For Your Records APR for Csh Advnces Penlty APR nd When it Applies 29.99% 29.99% This APR my be pplied to your Account if you mke lte pyment. How Long Will the Penlty APR Apply? If your APRs re incresed for this reson, the Penlty APR will pply until you mke six consecutive minimum pyments when due. Pying Interest Minimum Interest Chrge For Credit Crd Tips from the Federl Reserve Bord Your due dte is t lest 23 dys fter the close of ech billing cycle. We will not chrge you ny interest on purchses if you py your entire blnce by the due dte ech month. We will begin chrging interest on csh dvnces nd blnce trnsfers on the trnsction dte. If you re chrged interest, the chrge will be no less thn $2. To lern more bout fctors to consider when pplying for or using credit crd, visit the website of the Federl Reserve Bord t Fees Trnsction Fees Blnce Trnsfer Csh Advnce Either $5 or 4% of the mount of ech trnsfer, whichever is greter. Either $5 or 4% of the mount of ech csh dvnce, whichever is greter. Penlty Fees Lte Pyment Returned Pyment Up to $35 Up to $35 How We Will Clculte Your Blnce: We use method clled dily blnce. See your Credit Crd Agreement for more detils. Billing Rights: Informtion on your rights to dispute trnsctions nd how to exercise those rights is provided in your Credit Crd Agreement. The informtion bout the costs of the Account described herein is ccurte s of 11/15/2010. This informtion my hve chnged fter tht dte. To find out wht my hve chnged, write us t GEMB, P.O. Box , El Pso, TX Plese red the following disclosure if you hve received pre-pprovl for credit crd You cn choose to stop receiving prescreened offers of credit from this nd other compnies by clling toll-free See PRESCREEN & OPT-OUT NOTICE below for more informtion bout prescreened offers. PRESCREEN & OPT-OUT NOTICE: This prescreen offer of credit is bsed on informtion in your credit report indicting tht you meet certin criteri. This offer is not gurnteed if you do not meet our criteri. If you do not wnt to receive prescreened offers of credit from this nd other compnies, cll the consumer reporting gencies toll-free, t , or write to: Trns Union, Attn: Mrketing Opt Out, P.O. Box 505, Woodlyn, PA ; Equifx Options, P.O. Box , Atlnt, GA ; or Experin Opt-Out, P.O. Box 919, Allen, TX