Why Choose Castleman Eye Center for your LASIK procedure?



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Lawrence D. Castleman, M.D. James Valice, M.D. Snigdha Singh, M.D. John M. Ramocki, M.D. Why Choose Castleman Eye Center for your LASIK procedure? 1. We have our own dedicated State of the Art LASIK Operating Suite in our Troy office where we personally oversee the maintenance and safety of the equipment. There are some lasers that are transported from office to office on a daily basis. It is important to maintain temperature and humidity at all times for the laser to function properly. 2. We have performed over 9,000 Laser Vision Correction Procedures and have been in practice for over 40 years. Dr. Singh received Vitals (a leading physician review site) Patient s Choice Award and Compassionate Doctor Recognition for 2012, along with a 4 out of 4 Stars Rating. 3. We offer ALL LASER LASIK (ilasik). The LASIK flap is created with a LASER, not a blade. Eliminating the blade, gives you a safer, more precise LASIK. In fact, all branches of the U.S. Military only recommend ilasik technology for their servicemen and women. 4. We offer FREE Consultations and No money down, ZERO INTEREST FINANCING for 2 Years through Care Credit. 5. All inclusive pricing, no hidden fees. Our fees include pre-op testing, surgery and post-op care for one year. Owning our laser enables us to offer very competitive pricing. 6. Our surgeons are all board certified, licensed ophthalmologists, each with over 14 years experience. 7. Our VISX certified, surgical support staff each have over 14 years experience assisting doctors in thousands of LASIK surgery procedures. 8. We use the VISX S4 Laser and CustomVue Wavescan Technology. The Wavescan produces a detailed map of the eye, much like a fingerprint, and translates these digital treatment instructions directly to the VISX S4 Laser. The CustomVue procedure then tailors a distinct correction for each eye, which corrects unique imperfections, providing a new level of accuracy and high definition vision. Not all lasers have this capability. 9. All pre-op and post-op care is provided by your surgeon, not ancillary staff. 10. We are conservative with our recommendations. We won t perform the LASIK procedure if we don t think you will achieve excellent results. 11. We offer many discount programs. Visit our website at www.castlemaneyecenter.com for more information. 12. Our surgery center was named one of the 100 Best Places to Work in Healthcare by Becker s ASC Review. 13080 Eureka Rd Southgate MI 48195 Tel: (734) 283-0500 Fax: (734) 283-2720 113 E. Long Lake Rd Troy, MI 48085 Tel: (248) 813-0099 Fax: (248) 813-0210

LASIK EXAM INFORMATION Thank you for choosing Castleman Eye Center for your LASIK evaluation. What to expect: 1. Your consultation with our ophthalmologist will last approximately 2 hours. 2. To perform a complete eye examination for LASIK, your eyes will be dilated. This causes light sensitivity and blurry near vision and may last for 24 hours. 3. If you are concerned about driving while dilated, please have a driver accompany you. 4. Bring your current eyeglasses (or prescription) with you, as well as sunglasses--we can provide sunglasses if needed. 5. LASIK fees vary based on your level of correction and will be determined during your appointment. CONTACT LENS PATIENTS IMPORTANT!! If Your Contacts Are: Hard Contacts/Rigid/Gas Permeable Do not wear contacts for 3 full weeks prior to exam Soft Extended Wear If you sleep in your contacts for Do not wear contacts for 2 full weeks prior to exam up to a week at a time Soft Extended Wear If you sleep in them for more Do not wear contacts for 3 full weeks prior to exam than 2 weeks at a time Soft Daily Wear If you never sleep in contacts Do not wear contacts for 2 weeks prior to exam LASIK PROCEDURE INFORMATION You and your doctor decide together which LASIK option is best for you. There are 2 steps involved in LASIK procedures: o Step 1 is Flap Creation and can be done by a blade or Laser (ilasik). o Step 2 is reshaping your cornea and can be done using a Standard treatment (based on your eye exam) or CustomVue Advanced treatment (uses a computerized map of your eye for treatment). The preferred method is CustomVue Advanced LASIK (ilasik) due to precision results and less risk of flap complications. o The vast majority of ilasik patients see 20/20 or even better! You are awake during the LASIK procedure, but you will be given a mild sedative pill to help you relax. Your eyes will be numbed with drops, and aside from a little pressure, YOU MOST LIKELY WON T FEEL A THING during the procedure. Both eyes are treated at the same visit and most patients return to work the next day. The LASIK procedure takes less than 15 minutes. Appointment Date: Time: 13080 Eureka Rd Southgate MI 48195 1-800-403-0060 113 East Long Lake Rd Troy MI 48085 u:ceclasik:procedurefeeinfo

PATIENT NAME E-MAIL ADDRESS HOME PHONE# ALTERNATE PHONE# Work / Cell / Other ADDRESS CITY STATE ZIP SEX AGE BIRTH DATE MARITAL STATUS MI SOCIAL SECURITY NUMBER S M D W NOTE: The information below is a reporting requirement of the government Patient Protection and Affordable Care Act 2010. We are obligated to obtain this information from our patients. Race: White Ethnicity: American Indian or Alaska Native Asian Hispanic Not Hispanic Black or African American Language Preference: English or Native Hawaiian or Other Pacific Islander EMPLOYER Other: OCCUPATION SPOUSE NAME SPOUSE S EMPLOYER NEXT OF KIN ( For office use only: remember to add to P Partner) NAME: PHONE: MEDICAL INSURANCE INFORMATION Primary : Subscriber Name/Bdate(if diff than pt): Secondary: Subscriber Name/Bdate: Tertiary: Subscriber Name/Bdate: VISION INSURANCE Primary Secondary U:workgroups:forms

MEDICAL HISTORY QUESTIONNAIRE Patient Name: Birth Date: Referring Doctor: PHONE Address CITY ZIP Primary Care Physician: PHONE Address CITY ZIP Pharmacy Name: Address CITY ZIP Allergies (drug, food or substance) & Reaction Severity mild / moderate / severe mild / moderate / severe Past Ocular History: (Please mark all that apply) No History of Eye Disease Cataracts Hyperopia (Far sighted) Myopia (Near sighted) Amblyopia (Lazy eye) Diabetic Retinopathy Iritis Optic Neuritis Aphakia Dry Eyes Keratoconus Retinal Detachment Astigmatism Glaucoma Macular Degeneration Other Eye Surgeries: (Please mark all that apply & list dates) Glaucoma laser surgery No Prior Eye Surgery Foreign Body Removal Punctal Plugs Trabeculectomy Blepharoplasty Retinal Laser Surgery RK (Glaucoma surgery) Cataract Surgery LASIK Strabismus Surgery Vitrectomy/Retina Surgery Corneal Transplant PRK (eye muscle surgery) Other Current Eye Drops/Meds: (Please list) _ Medical Illnesses (if yes, indicate # of years): Overall Healthy Congestive Heart Failure Hepatitis A B or C Lung Disease Anemia COPD High Blood Pressure yrs Lupus Arthritis Diabetes yrs High Cholesterol Migraine Arrhythmia Eczema Graves Disease Polymyalgia Asthma Fibromyalgia Kidney Disease Psychiatric Disorder Bleeding Disorder Headache Kidney Stones Skin Cancer Cancer Hearing Loss Liver Disease Stroke Thyroid Disease AIDS/HIV positive Lupus Mult. Sclerosis(MS) Herpes/Shingles Sjogrens Rheumatoid Arthritis Histoplasmosis Toxoplasmosis Insulin? Yes No Plaquenil for Rheumatoid Arthritis? Yes No Other General Surgeries / Operations: (Please list all & dates) Please continue on the back side of this page

Current Medications: (Please list) Family History (Mother, Father, Siblings, Grandparents): Diabetes Stroke Blindness Macular Degeneration Arthritis Cancer TB Cataracts Retinal Disease Lazy Eye Heart Disease Kidney Disease Glaucoma High Blood Pressure Other Social History: (Please mark all that apply) Smoking: current every day smoker current some day smoker former smoker never smoked Alcohol Use: Yes No If yes how much and how often? Drug Use: Yes No If yes what and how often? Eyes Previous Surgery Contact Lens Pain Double Vision Glaucoma Cataracts Macular Degeneration Dry Eyes Flashes Floaters Respiratory Cough Congestion Wheezing Asthma Gastrointestinal Heartburn Nausea / Vomiting Jaundice / Hepatitus Blood / Lymphnodes Easy Bruising Gums Bleed Easy Prolonged Bleeding Heavy Aspirin Use MusculoSkeletal Stiffness Arthritis Joint Pain / Swelling Ear, Nose, and Throat Hard of Hearing Ringing in Ears Vertigo Cardiovascular Chest Pain Dizziness Fainting Spells Shortness of Breath Irregular Heart Beat Difficulty Lying Flat Constitutional Fatigue / Weakness Fever Weight Gain / Loss Genito-Urinary Pain / Difficulty Blood in Urine History of Kidney Stones History of STD s Psychiatric Anxiety / Depression Mood Swings Difficulty Sleeping Endocrine Increased Thirst Increased Hunger Increased Urination Increased Sweating Fingernail Changes Skin Rash / Sores Lesions Hives / Eczema Neurological Seizures Weakness / Paralysis Numbness Tremors Immunologic Hives Itching Runny Nose Sinus Pressure Review of Systems: (Please mark all that apply)

Am I a Candidate? Castleman Eye Center Changing Lives Through Vision Perhaps the greatest news about ilasik is that the majority of people with nearsightedness, farsightedness as well as astigmatism are candidates for this state-of-the-art vision correction procedure. With the use of a bladeless flap creator, and the wide range of vision imperfections that the FDA-approved treatment laser can correct, more people than ever before are excellent candidates for laser vision correction. If you answer true to all the following criteria, it s time for you to schedule an evaluation with your ilasik surgeon today! *FREE LASIK Consultation *0% Financing for 2 Years *All Inclusive Pricing-No Hidden Fees *Vitals Patient's Choice Award 2012 *Over 9000 Procedures Performed *LASIK Discount Program for Vision Plans *Over 40 Years in Practice The Future of Laser Vision Correction is Here I am in overall good health. I have had a stable eye prescription for at least one year. I have no existing eye diseases. I am at least 21 years old. I want to change my life and lifestyle with freedom from glasses and contacts. Castleman Eye Center 13080 Eureka Road Southgate, MI 48195 PH: 800.403.0060 F: 734.283.2720 www.castlemaneyecenter.com Castleman Eye Center Changing Lives Through Vision 800-403-0060

Truly Customized All-Laser LASIK If you ve been waiting for the best in vision correction technology, your wait is over. All-laser ilasik combines the very latest of three FDA-approved technologies to provide a truly customized LASIK procedure tailored specifically for your vision imperfections. Although surgeons have been performing LASIK procedures with great success over the past decade, never before has laser vision correction been able to address each individual s vision needs with such precision and deliver such great results. ilasik in Action Every process in ilasik is customized for you, and aids the surgeon in getting the best possible results for your laser vision correction procedure. There are three main steps to the ilasik procedure. Step 1: WaveScan Map The first step in ilasik is the preparation of the WaveScan 3-D map. Through a series of tests, this tool maps out all the imperfections in your vision so your personalized vision correction plan can be formulated for the Advanced CustomVue vision correction laser. Step 2: Intralase Laser Although complications are rare, in conventional LASIK the majority occur during the creation of the flap with the microkeratome blade. The Intralase Laser used in ilasik eliminates these types of complications. The flap, created with the Intralase Laser, is a thinner, more precise flap that allows for faster healing of the cornea. Step 3: Advanced CustomVue laser vision correction The last step in creating vivid and clear vision for you is the custom laser treatment on your cornea. The WaveScan map provides the surgeon and the laser s computer the information needed to reshape your cornea for your best vision possible. The cool beam of light treats the cornea painlessly and precisely, in just a matter of seconds. What s The Next Step? If you ve been thinking about vision correction for a while now but haven t been able to commit, or you ve been told in the past you weren t a candidate, now is the time to re-evaluate. If your concerns are over results, ilasik addresses those concerns for most people. In clinical studies, 100% of nearsighted patients and 95% of all participating patients could pass a driver s test without glasses or contacts one year later. In addition, 98% of patients with mild-to-moderate nearsightedness obtained 20/20 vision or better. If you weren t a candidate for conventional LASIK because you required treatment outside the approved parameters, or your corneas were too thin, you may now be a candidate for ilasik. ilasik is opening the doors to a future of better vision for many people who were not previously eligible. If you have questions about affordability, most surgeons and LASIK centers have partnered with 3rd party financing companies to offer affordable monthly payments. Your next step is to schedule an evaluation or consultation with an ilasik surgeon to discuss your concerns in detail, confirm you are a candidate and then schedule your surgery date. It s as simple as that! You ll be enjoying your new vision before you know it and you ll wonder why you waited so long. New NASA guidelines specify that only ilasik may be performed on its astronauts using precise measurement and wavefront-guided lasers. 2008 #35739 Doctordirect

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