On Your Day of Surgery:

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1 Please review all instructions for your Lasik/ASA procedure carefully. Call our office ( ) with any questions you may have before the day of your procedure. If you are a gas permeable or hard contact lens wearer, you must be out of your contact lenses for 1 month prior to surgery. If you are a soft contact lens wearer, you must be out of your contact lenses for two weeks before your surgery. On Your Day of Surgery: Please refrain from wearing any type of perfume, cologne, scented lotions, and all hair products containing alcohol (mousse, gel, hair spray). Face should be clean of any and all make-up the day before and the day of your surgery, with the exception of an unscented moisturizer. Your surgery will be cancelled if any of the above is present the day of your procedure. Please have your Zymar, Besivance, Vigamox, or Ocuflox prescription filled and bring the drops the day of surgery. You will only need one of those medications not all 4. We will instruct you on post-op use of your drops when you come in the day of surgery. Additional drops will be provided to you. Restasis may be necessary and if you receive a prescription it may also be filled prior to surgery, however, you will not use it for the first week after surgery. It will then be used twice a day for the first 3-6 months following your LASIK. Arrange to have transportation the day of your procedure as well as for the 24-hour follow-up. This is also necessary even if you are only having surgery on one eye and for all enhancements. We will have to cancel your surgery if you do not have a ride for that appointment. Your 24-hour post op appointment will be the following day between 8:00-9:00am unless otherwise discussed. Be sure to dress warmly on the day of surgery, as the operating room is kept at a cool temperature. Eat something before arriving for surgery. Please bring consent form filled out completely before arriving for surgery! Payment is due in full on the day of surgery unless other arrangements have been made prior to the day of surgery. We accept personal checks, Visa and MasterCard. 6/1/2005 Patient Consent Form Page 1 of 11

2 INITIALS Patient Consent Form Page 2 of 11

3 Washington Pacific Eye Associates PATIENT CONSENT FORM(S) LASIK (LASER IN SITU KERATOMILEUSIS) ASA (ADVANCED SURFACE ABLATION) INITIALS Patient Consent Form Page 3 of 11

4 1. I understand that I am a candidate for LASIK (LASER IN SITU KERATOMILEUSIS) SURGERY, a form of laser surgery where a surgeon will anesthetize my eye with a topical anesthetic, create a flap from my cornea using a specialized instrument, and use an excimer laser to reshape the cornea. Patient Initial for Lasik: And / Or 2. I understand that I am a candidate for ASA (ADVANCED SURFACE ABLATION) SURGERY, a form of outpatient surgery in which a surgeon uses a device called an excimer laser to reshape the cornea. Patient Initial for ASA: LASIK or ASA, the identified surgery, is referred to as the procedure in the following. 3. I understand the procedure will be performed by Jennifer Lee M.D. on this day of 2010 a. On both eyes [INITIAL]; or b. On my right eye on [Date] [INITIAL] c. And on my left eye [Date] [INITIAL] 4. I have reviewed the Surgical Information Package for LASIK surgery and for ASA and I have discussed the procedure that I am to receive with an eye care professional at the office and with my surgeon. 5. The nature of the procedure, the possible complications and risks, as well as the possible benefits of the procedure, the alternatives to the procedure and the risks and benefits of those alternatives have been explained to me in language and using terminology that I understand. My surgeon has answered all of my outstanding questions about the procedure. INITIALS Patient Consent Form Page 4 of 11

5 6. I understand that this procedure is an elective surgical procedure, and that there is no emergency or medical condition that requires that I have the procedure. 7. Neither my surgeon, nor the office staff has made any promises, warranties, or guarantees as to the success or effectiveness of the procedure. I have been advised that after the procedure, my vision may not be as clear and sharp as it was with glasses or contact lenses before the procedure. 8. I understand that the procedure may not eliminate the need for corrective lenses for all activities and that after the procedure, I may need glasses or contact lenses for reading, driving, or certain other activities, even if I did not wear them before. I also understand that the procedure can unmask the need for reading glasses, and that I may have to use them after the procedure, even if I did not wear them before. 9. I understand that after the procedure I may experience side effects such as pain, discomfort and scratchiness, halos, blurry vision or fluctuations in vision, which may be temporary or could be permanent. I have been advised that I may find some of these side effects difficult to tolerate. 10. I understand that there are numerous risks and complications, both known and unknown connected with the procedure, including but not limited to infection, hemorrhage, delayed healing, under- or over-correction, and other risks and complications that could affect my vision and my general health on a temporary or permanent basis, and could require additional surgery, including but not limited to, retreatment or a cornea transplant. Those risks also include but are not limited to, partial or total blindness, loss of a cornea, retinal damage or loss of an eye. 11. I understand that the procedure is a relatively new procedure, and that little is known about its long-term effectiveness. 12. I understand that the procedure does not correct certain vision problems, including but not limited to amblyopia, strabismus, presbyopia, and cataracts. 13. I understand that the field of refractive surgery is continuing to evolve and that if I were to postpone my surgery there is the possibility that the LASIK and/or ASA procedure might be improved or some other procedure might become available. 14. I understand that my surgeon is a medical doctor and a board certified ophthalmologist and ophthalmic surgeon who is experienced with the LASIK and/or ASA procedure and INITIALS Patient Consent Form Page 5 of 11

6 has been credentialed to meet the standards required for certification by Washington Pacific Eye Assoicates. 15. I understand that I will need certain post-operative care. The standard post-operative LASIK care (24 hour, one month, and three months) will be at the office and is included in my LASIK package. As with most surgical procedures, three months of post-operative care related to that surgery is included at no additional charge. By three months the need for enhancements can usually be identified. If an appointment outside of the three month time frame is necessary there will be a charge for each visit. 16. I understand that other costs such as glasses, punctal plugs, contact lenses the cost of certain medications, or issues unrelated to my LASIK procedure are not included in the LASIK package. 17. I understand that the complete eye examinations are required annually. I understand that annual eye exams are not included in my LASIK package. 18. I understand that if I so desire, I may make other arrangements for post-operative care at my own expense. If this is my choice, I confirm that I have made arrangements to have my post-operative care provided by M.D./O.D., who is an ophthalmologist /optometrist (circle one) located in. 19. I have had the opportunity to ask questions about the procedure and all of my questions have been answered satisfactorily. 20. I give permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential, unless I give written permission for the disclosure of such information. (Patient may delete this clause if choose not to participate in research activities.) 21. I give permission to videotape or photograph the procedure. (Patient may decline to be video taped and may delete this clause.) 22. If my surgeon, Jennifer J. Lee, M.D., has advised me that I have a higher possibility of complications or risks arising from the procedure because I have certain medical conditions or risk factors, I understand that I am required to complete separate consent forms, which address my condition and/or risk factors. 23. I am not under the influence of any sedative. I am of clear mind and understand the nature of the procedure and the possible risks related to the procedure. INITIALS Patient Consent Form Page 6 of 11

7 I understand that by signing below, I am indicating that I have read and understood the information in this patient consent form, that I have been verbally advised about the procedure, that I have had an opportunity to ask questions, that I have received all of the information I desire concerning the procedure, and that I authorize and consent to the performance of the procedure and any different or further procedures which in the opinion of my surgeon are necessary due to an emergency. Patient s Name (please print): Patient s Signature: Witness to Patient s Signature: Surgeon s name (please print): Jennifer J. Lee, M.D. Surgeon s Signature: Date: INITIALS Patient Consent Form Page 7 of 11

8 CERTIFICATION BY SURGEON I, Jennifer J. Lee, M.D., hereby certify that: 1. I have discussed and explained LASIK (Laser in Situ Keratomileusis) or, ASA (Advanced Surface Ablation) [please circle one], referred to as the procedure, the risks and benefits of the procedure, the alternatives to the procedure and the risks and benefits of those alternatives with (the patient ). 2. The patient is a suitable candidate for LASIK or ASA (please circle one) given the ophthalmic findings and the Patient s physical, social, emotional and/or occupational needs. 3. I have discussed any special circumstances with the patient and the additional potential risks posed by those special circumstances, including the following: (TO BE COMPLETED BY SURGEON) 4. I have discussed the arrangements for postoperative care with the patient, who has agreed to the plan for post-operative care. 5. I have answered all of the patient s questions about the procedure. 6. I have ascertained that the patient fully understands the answers to questions that he/she posed to me. 7. I have ascertained that the patient fully understands the risks, benefits and possible, alternatives to the procedure. Name of Surgeon: Jennifer J. Lee, M.D. Signature: Date: INITIALS Patient Consent Form Page 8 of 11

9 CONSENT FORM ADDENDUM/CONFIRMATION* Please read and copy the following sentences in your own handwriting to confirm that you agree and clearly understand them. 1. I have decided that the benefits of surgery outweigh the potential for complications. 2. I understand that my vision under low lighting conditions may be impaired, particularly with respect to night vision disturbances such as glare and halo and that glasses or contact lenses may not be able to correct these. 3. I understand that in the event of a serious complication, my vision would be blurred, doubled or distorted and that neither glasses nor contact lenses would be able to correct this. 4. I understand that I will still need glasses for near vision at or about the age of 40 * This Form highlights only some of the important concepts I need to understand before undergoing surgery. I understand that other information in the Surgical Information Packet and Consent Form for LASIK/ Laser In Situ Keratomileusis may be equally or more important for my situation. Name (printed): Signature: Date: INITIALS Patient Consent Form Page 9 of 11

10 ENHANCEMENT POLICY All patients who have LASIK/ASA surgery at Bellevue LASIK are automatically enrolled in the enhancement guarantee program. The program provides eligible patients with enhancements for eighteen months following their surgery subject to the following eligibility requirements, exclusions, and fees. Generally only one enhancement per eye would be performed. It is extremely unusual to need more than one and the risk of causing worse vision increases with each laser procedure. ELIGIBILITY To remain eligible for the enhancement guarantee the patient must complete the required post-op care. During the post-operative healing period, examinations are required at one day, one month, and three months. Thereafter a complete eye examination is required annually (not included in the procedure fee). If these are performed elsewhere, the examining ophthalmologist or optometrist must complete the standard follow-up form and return it to Washington Pacific Eye Associates at the required interval. If the post-op visits are not completed and reported, the enhancement guarantee is invalidated. These visits are required so that any problems with the healing process would be noted and dealt with early to assure the best possible outcome. The data collected at the post-op visits also allow us to continue tracking outcomes and further refining our nomograms. Generally, enhancements are performed if the vision regresses to 20/40 or worse. However, visual requirements and the need for an enhancement vary by individual. Enhancements are occasionally performed for vision better than 20/40. Your surgeon will counsel with you and will make the final decision regarding the advisability of an enhancement. Enhancements generally are not performed before three months post-op for residual myopia and 6 months post-op for residual hyperopia. EXCLUSIONS The majority of patients will qualify for the enhancement guarantee. However, the following exclusions apply: Patients who have had previous refractive eye surgery of any type because results for these patients are less predictable. Patients whose visual changes following LASIK/ASA are due to any process other than the normal variation in healing. For example: cataracts, trauma, and disease. INITIALS Patient Consent Form Page 10 of 11

11 Patients who become pregnant within 6 months following their surgery or who have not informed us of recent pregnancy or breast-feeding within 3 months prior to their preoperative evaluation. FEES The enhancement guarantee is based on the technology at the time of your surgery. If advances in technology alter the recommendation, the enhancement would not be offered under this guarantee but may be offered at a fee less than new patient fees applicable at the time. If you do not complete the required post-operative examinations and reports the enhancement guarantee is invalidated. An enhancement may be available, if appropriate, at a 25% discount off the full LASIK fee at the time of the enhancement. If it has been more than eighteen months since the original surgery was performed, an enhancement may be available at a 25% discount off the full LASIK fee at the time of the enhancement. ENHANCEMENT POLICY CONFIRMATION Please read and copy the following sentence in your own handwriting to confirm that you clearly understand the enhancement policy. 1. To remain eligible for the enhancement guarantee I must complete and report the required post-op care. If you have any additional questions regarding this policy, please feel free to ask for clarification. Your signature below indicates that you have read and understood the terms of our enhancement commitment. Name (printed): Signature: Date: INITIALS Patient Consent Form Page 11 of 11

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