All glaucoma patients please use eye drops morning of appointment and bring them with you to your appointment.

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1 Thank you for choosing BVA Advanced Eye Care for your cataract evaluation. We look forward to seeing you during your visit and are excited to help restore your vision. Over the last 20 years cataract surgery has evolved to be one of the safest and most reliable methods to restore vision. The advancements in medical technology now allow new options for patients considering cataract surgery who also want to become less dependent on glasses. The purpose of this letter is to let you know that you will need to make a decision following your evaluation about the type of lens implant that you would like. Depending on the complexity of your prescription, certain lens implants may be better suited to help you become less dependent on glasses. We will discuss your options and make recommendations based on your prescription and your lifestyle. There are also new options in the way cataract surgery is performed. Traditional cataract surgery has been a tried and true procedure that has been perfected for many years. To improve the precision of the surgery, several of the steps of traditional cataract surgery can now be aided by the use of a femtosecond laser. This technology can help with the predictability of the visual outcomes when combined with our specialty lens implants. We have enclosed information about both the lens implant options and the laser cataract surgery option. Please review these prior to your appointment to help us determine the best approach to cataract surgery if needed. It is very important to discontinue wearing Contact Lenses 2 weeks prior to your evaluation. If you were Hard/Gas Perm Contact Lenses, please contact our office for instructions. Failure to remove your contact lenses could result in having to reschedule your appointment. All glaucoma patients please use eye drops morning of appointment and bring them with you to your appointment. Please be aware that insurance does cover traditional cataract surgery but not the upgraded options. The exact cost will be discussed with you by our patient counselors. Thank you for trusting us with your vision. We care about you and will do everything possible to help you see clearly once again. Larry R. Henry, O.D., F.A.A.O., Diplomate ABO Clinical Director, BVA Advanced Eye Care

2 Traditional Cataract Surgery Our eye functions much like a camera. The natural lens inside our eye focuses images onto the back of the eye so we can see clearly, much like the lens of a camera focuses images onto film for a clear picture. At birth, our natural lens is clear, but as we age it yellows, hardens and may become cloudy. This condition is called a cataract, and is a result of the natural aging process. As the natural lens becomes cloudier, vision becomes more blurred. Traditional cataract surgery is one of the most routinely performed surgeries in the United States. It has a very safe and effective outcome when performed by a skilled surgeon. Surgery is performed in a fully-accredited outpatient surgery center. Patients need not expect to stay at the surgery center for more than a couple of hours. Prior to surgery, patients are given a relaxant to enhance calmness. Patients do not have to remain under anesthesia and should neither see nor feel any part of the surgery. Through a microincision, the cataract is dissolved and removed from the eye using ultrasound technology. The cataract is then replaced with a foldable lens implant through the original micro-incision. The incision is self-healing and heals without stitches. Since no eye patch is used, the eye can be used for vision immediately after surgery. Because the pupil will still be dilated after surgery, your eyesight may be somewhat blurry but will gradually improve over the next few days. After a short stay in the outpatient recovery area, you will be ready to go home. You are required to have someone drive you home and you should plan to have a responsible adult remain with you for a few hours following surgery. Monofocal Lens Traditional cataract surgery uses a standard single-focus lens, or monofocal, lens implant to replace the clouded natural lens to help improve vision. Patients who have a simple nearsighted or simple farsighted prescription may only need reading glasses following traditional cataract surgery. Full-time glasses, however, may still be needed for patients whose prescriptions are more complex.

3 Patients with more complex prescriptions, known as astigmatism, will still need to wear full-time glasses following traditional cataract surgery. Astigmatism is due to an irregular shape of the cornea. This irregular shape of the cornea can cause blurring, distortion or even doubling of the vision. Cataract surgery can be customized in two ways to surgically correct astigmatism depending on its severity: Mild Astigmatism can typically be reduced with a simple surgical procedure known as Astigmatic Keratectomy (AK). AK is performed during the cataract surgery to reshape the cornea into a more rounded surface. Moderate and higher amounts of astigmatism can be corrected with a Toric lens implant, a lens implant specifically designed to correct astigmatic prescriptions. The toric lens implant must be carefully positioned during surgery to compensate for the irregular-shaped cornea. Although custom cataract surgery for astigmatism improves the patient's vision in the distance, there will still be a need for reading glasses.

4 Multifocal and Accommodating IOLs are designed to eliminate your need or reduce your dependence on glasses after cataract surgery compared to the traditional monofocal IOLs. They are designed to provide both distance (far away) and near (close up) focus at all times. Multifocal IOLs work differently from bifocal eyeglasses. With bifocals, you look through the top part of the lens for distance vision and the bottom part for near vision. A multifocal IOL has concentric rings that help your brain select the right focus automatically. Like wearing bifocals, this can take time. Your vision without glasses usually improves gradually over the first year. An Accommodating IOL is one that can move or change its shape in the eye. By doing this it changes its power so that it can focus from near to far. The only accommodating lens currently available is the Crystalens. This is wonderful technology and is very useful for those people who want the crispest distance vision as well as an excellent ability to see intermediate distance which includes things like the computer screen, grocery store shelves, and auto gauges. In fact, much of our time is spent looking at things in the intermediate range. Most people who receive the Crystalens in both eyes are thrilled with the quality and range of vision. The one drawback of this lens is that some people will still need glasses for very close vision and when trying to read the smallest print. The rings of multifocal IOLs can create halos - a glow around lights at night. This depends partly on the size of your pupils, the area where light enters your eye. The amount of light affects halo size. With time, your brain gradually adapts, and most people with multifocal IOLs feel this effect is minor. TECNIS Symfony Crystalens

5 Just as you have options when it comes to choosing the lens that you receive during cataract surgery, you also have the option of choosing the technology that is used to perform the procedure. This means you have a choice between traditional cataract surgery or cataract surgery with the assistance of laser technology. For patients that want cataract surgery performed with the precision and accuracy of a laser, BVA is proud to offer the CATALYS Precision Laser System. Using femtosecond laser technology, the CATALYS System is able to automate some of the more technically demanding steps of the traditional cataract surgery. This can make laser-assisted cataract surgery procedures more predictable and precise, specifically in three areas: 1) The laser makes more precise incisions during cataract surgery to gain access to the cataract lens. 2) The laser pre-softens the cataract prior to removal to minimize the need for ultrasound energy during the surgery. 3) The laser can be used for more precise and predictable astigmatism correction at the time of cataract surgery by resculpting an irregular corneal surface. Re-sculpting reduces the need for distance glasses for patients with complex prescriptions. Please Note: Most cataract surgery upgrades are considered a premium refractive surgery by insurances and require out-of-pocket charges. We will be happy to discuss this with you during your visit, as well as flexible payment plans.

6 Account # Patient Information Name: Date of Birth: Age: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) SS# Employer: Employer Address: City/State/Zip: Follow-up Preference: Phone Mail Race: American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander White Prefer not to answer Ethnicity: Hispanic or Latino Not Hispanic or Latino Prefer not to answer Preferred Language: English Spanish Other Sex: Male Female Marital Status: Married Single Divorced Widowed Optometrist: Referring Physician: Primary Care Physician: How did you hear of BVA? Family/Friend Insurance Plan Optometrist Ad Other Insurance Information Primary Insurance: I.D.#: Group #: Secondary Insurance: I.D.#: Group #: Primary Insured/Responsible Party Information (if different from patient information) Name: Relationship to patient: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Reason for Today s Visit Cataract Glaucoma Diabetic Eye Exam Other If this visit is due to an accident, please provide accident date:

7 Patient Name: DOB: Medical History - Please check all that apply: Blindness Kidney Disease Sjogren s Cataracts Lung Disease Alzheimer s/dementia Diabetic Retinopathy Lupus Glaucoma Stroke Macular Degeneration Thyroid Retinal Detachment AIDS/HIV Arthritis (Type ) Bleeding/Clotting Cancer Ever taken Flomax? Heart Disease Hepatitis (Type ) High Blood Pressure Sleep Apnea High Cholesterol Other: Diabetes - If yes, year diagnosed: Most recent blood sugar reading: :AIC Family History - Ocular Disease - Please check if a family member has any of the following: Macular Degeneration - Family relation: Glaucoma - Family relation: Diabetes - Family relation: Social History Are you pregnant? Yes No Do you smoke? Yes No Packs per day? # of Years? Previous smoker? Yes No Year quit Packs per day? # of Years? Do you drink alcohol? Yes No Drinks per week: Do you drive? Yes No Do you have visual difficulty when driving/or problems with night vision? Yes No Do you wear contacts? Yes No Type Hours per day Date last worn Do you wear glasses? Yes No Please check YES or NO to indicate if you are currently experiencing any of the following: Loss of Vision Yes No Distorted Vision Yes No Fluctuated Vision Yes No Double Vision Yes No Loss of Side Vision Yes No Mucus Yes No Dryness Yes No Sandy or Gritty Feeling Yes No Redness Yes No Foreign Body Sensation Yes No Burning or Itchy Yes No Glare and Light Sensitivity Yes No Excess Tearing/Wate r ing Yes No Infection of Eyelid Yes No Eye Pain or Soreness Yes No Crossing Eyes Yes No Tired Eyes Yes No Drooping Eyelid Yes No Lazy Eye Yes No Flashes of Light/Floaters Yes No Blurred Vision Yes No - Page 1 of 2 -

8 Pharmacy Name: Location: Phone: List Current Medications (including EYE drops): Drug Name Dosage Times per day Drug Allergies No known allergies Latex Allergy Sulfa Allergy Adhesive Tape Other/ Medication Allergy Describe Allergic Reaction: Please List Your Height: Weight: [Information required for surgery patients.] Please List All Past Surgeries & Surgery Dates (including EYE surgeries):

9 - Page 2 of 2 - CONSENT FOR DILATING EYE DROPS WHILE UNDER THE CARE OF BVA DOCTORS A variety of eye drops may be administered during the course of your eye examination. Dilating drops enlarge the pupils of the eye to allow for the examination of the inside of your eye. These drops usually cause blurred vision. The length of time vision will be blurred and the degree of eyesight impairment varies from person to person. It is not possible for your doctor to predict how much or how long your vision will be affected. Driving even in low light conditions may be difficult or impossible after an examination with dilating drops, and, if possible you should not drive yourself afterwards. Instead, we strongly suggest you make alternate arrangements for transportation after your examination. If you choose to drive yourself, you acknowledge that you understand the risks and accept full responsibility for any injuries to yourself or others. Also, we strongly suggest you use sunglasses to reduce your increased sensitivity to light while driving. Although uncommon, the potential for adverse reactions from eye drops does exist, such as acute angle-closure glaucoma, which may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. You hereby authorize BVA doctors and/or assistants to administer dilating eye drops or other eye drops during the course of your treatment. You understand that these eye drops are necessary to diagnose your condition. You further understand and acknowledge that you have been warned of the potential risks that dilating eye drops may have on your ability to drive and will take appropriate steps to reduce this risk by not driving immediately after your eyes have been dilated or by wearing sunglasses while driving. Patient (or patient s authorized representative) Date

10 Patient Name: DOB: PATIENT AUTHORIZATION Assignment of Medicare and Insurance Benefits and Acknowledgement of Privacy Practices I request that payment of authorized Medicare, Medigap, or any other insurance be made on my behalf to BVA Advanced Eye Care for any service furnished to me by a physician of the group. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services (CMS), or any other insurers and its agents any information needed to determine these benefits payable for related services. In Medicare assigned cases, or insured contracts, the provider agrees to accept the charge determination of the Medicare carrier or insured contracts, I am responsible for the deductible (Medicare deductible $183.00), co-insurance (or the 20% Medicare) or insurer does not pay, and for any non-covered services. I understand I am responsible for my bill in the event Medicare or my insurer denies the claim. I authorize release of medical records to my primary care physician or any other physician associated with continuity of my care. I authorize BVA Advanced Eye Care, its assignees, and third-party collection agents to utilize all contact information I have provided to communicate with me. This includes, but is not limited to, home telephone, cellular telephone, and employment telephone. I hereby grant permission and consent to BVA Advanced Eye Care, its assignees, and third-party collection agents to place calls to my home telephone, cellular telephone, and employment telephone; leave messages (whether voice or text); and utilize pre-recorded/artificial voice messages and/or automatic dialing devices in connection with any communication to me. Additionally, I understand that some procedures/services performed by the physician(s) may not be covered by my insurance plan. If services are not covered, I understand and agree to be financially responsible for payment for such services. AUTHORIZATION OF CARE I authorize BVA to examine me and perform such tests and procedures as are reasonable and necessary in the diagnosis and treatment of my care. If I am not the patient, but instead signing on behalf of the patient, I further certify that I am legally authorized to sign on the patient s behalf. Signature: Date: Representative Signature: Date:

11 PATIENT RECORD OF DISCLOSURE The HIPPA privacy rule provides individuals with the right to request a restriction on notes and disclosures of their protected health information. Persons to whom my personal health information may be discussed and/or released: Name: Relationship: Phone #: Name: Relationship: Phone #: No one other than myself. Your signature authorizes BVA Advanced Eye Care to disclose information about you to the person(s) indicated above. If applicable, this may include information relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse. This release is valid unless revoked, in writing, and signed by you. However, such revocation will not effect disclosures made in regard to any previous authorization. NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received or have been given the opportunity to receive a copy of BVA Advance Eye Care s Notice of Privacy Practices. By signing below, I am only giving acknowledgement that I have had the opportunity to review the Notice of Privacy Practices. The HIPAA Privacy Notice can be accessed online at or in the BVA office. Patient s Signature Representative s Signature Date Date Relationship of Representative to patient

12 Larry Henry, O.D. Brad Britton, M.D. Brad Taylor, D.O. Don Nguyen, M.D.

13 Your appointment is scheduled at: Don Nguyen, MD Brad Britton, M.D. Charles Ronan, OD BVA - South OKC Office BVA - Norman Office 220 SW 89th Street, Ste. D 3151 W. Tecumseh Road, Ste in the 9000 Cates Way Bldg. - in the Northwest Executive Park Patient: Appt. Date: Time: Location: South OK C Norman (405)