LASIK EXAM INFORMATION LASIK PROCEDURE INFORMATION
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- Erick Nelson
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1 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: Soft Contacts Do not wear contacts for 3 days prior to exam Hard Contacts/Rigid/Gas Permeable Do not wear contacts for 3 full 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: Eureka Rd Southgate MI East Maple Rd Troy MI u:ceclasik:procedurefeeinfo
2 Snigdha Singh, M.D. James Valice, M.D. Tiffany Humes O.D. Zachary D. Pearce D.O. 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 10,000 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 , 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 17 years experience. 7. Our VISX certified, surgical support staff each have over 17 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 for more information. 12. Our surgery center was named one of the 100 Best Places to Work in Healthcare by Becker s ASC Review Eureka Rd Southgate MI Tel: (734) Fax: (734) E. Maple Rd Troy, MI Tel: (248) Fax: (248)
3 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 information below is a reporting requirement of the government Patient Protection and Affordable Care Act We are obligated to obtain this information from our patients. Race: White American Indian/Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander EMPLOYER: SPOUSE NAME: ER CONTACT: Ethnicity: Hispanic Not Hispanic Language Preference: English Other OCCUPATION: SPOUSE EMPLOYER: PHONE: MEDICAL INSURANCE INFORMATION PRIMARY: SECONDARY: TERTIARY: Primary VISION INSURANCE Secondary FAMILY DR: ADDRESS/PHONE: PHARMACY: ADDRESS/PHONE: How were you referred to us? Patient/Family Google Internet Optometrist Insurance Location Family Doctor Other If Referred by Doctor please complete: NAME: ADDRESS: PHONE:
4 Medical History Questionnaire Patient Name: Date of Birth: 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 (if any): (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 Histoplasmosis 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 Toxoplasmosis Insulin? Yes No Plaquenil for Rheumatoid Arthritis? Yes No Other General Surgeries / Operations: (Please list all & dates) _ Current Medications: (Please list) ---Turn over for page 2---
5 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? Review of Systems: (Please mark all that apply): 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 Dry Eye Survey 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 Fluctuation in vision Redness Film over vision Burning Tired Eyes Watery Eyes Feeling of sand or grit in eye(s) Page 3
Why Choose Castleman Eye Center for your LASIK procedure?
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
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Margie Petersen Breast Center
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