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Tearwell, We Are a Unique Clinical Facility Dedicated Exclusively to The Welcome to TearWell, We are a unique clinical facility dedicated exclusively to the diagnosis and treatment of Dry Eye Syndrome. TearWell is located within the FocalPoint at Crosstown Concourse, in Suite 264 on the second floor of the historic Crosstown Concourse building at 1350 Concourse Avenue. Free parking is readily available in front of building and a covered parking garage. Remember not to use any eye drops 4 hours prior to your appointment, and no gel, ointments or contact lenses the night before. Also, please do not wear any eye makeup or thick lotions/ moisturizing creams near the eyes to avoid interference with some of the testing we will be performing during your evaluation. Your appointment will last between 1.5 and 2 hours and you will not be dilated or your vision affected in any way. Please bring a list of all your eye drops and other dry eye therapies you are currently using or have tried in the past, as well as a list of all medications you are currently taking. Enclosed is some of the paperwork we would have you fill out at the time of your visit, feel free to complete it before hand to expedite the check in process. We look forward to seeing you; let us know if you have any questions or if there’s anything else we can do before your appointment. Thank you, Ramon Gomez Eyecare Concierge 901.252.3670 [email protected] Making Your TearWell Appointment You’ve suffered from dry eyes long enough. Take the first step in NORTH PARKWAY finding lasting relief at the TearWell Advanced Dry Eye Treatment Center in midtown Memphis. TearWell has quickly become the leading center in the Mid-South for the diagnosis and treatment of dry eye disease. CROSSTOWN GALLOWAY AVE CENTRAL CONCOURSE ATRIUM With the expertise of three of the leading optometric physicians ST N WATKINS CONCOURSE AVENUE who have devoted much of their career to treating dry eye PARKING disease, TearWell additionally benefits from its association GARAGE with one of the nation’s leading optometry colleges and clinical AUTUMN AVENUE N CLEVELAND ST GARLAND ST facilities. Schedule your appointment today to begin a consultation to ST N CLAYBROOK explore the best treatment option for you. The TearWell Advanced Dry Eye Treatment Center’s primary Call 901.252.3670 or email [email protected]. location is open Monday-Friday from 8:30am - 5pm in The You may also visit TearWell.com to learn more. FocalPoint at Crosstown Concourse operated by Southern College of Optometry in Memphis. Located in Suite 264 on the Here’s how to visit us: second floor of the historic Crosstown Concourse building at 1350 Concourse Avenue, TearWell offers exclusive treatment DRY EYE options dedicated to the treatment of Dry Eye Disease and Located in The FocalPoint at Crosstown Concourse, operated by dry eye symptoms. Southern College of Optometry, in Suite 264 on the second floor of the historic Crosstown Concourse building at 1350 Concourse TearWell is conveniently located with 15-25 minute drives Avenue. TearWell offers exclusive treatment options dedicated from Collierville, Cordova, Germantown, Southaven and West RELIEF to the treatment of Dry Eye Disease and dry eye symptoms. Memphis. We offer free, convenient parking located in the Crosstown Concourse parking garage. TearWell is conveniently located with 15-25 minute drives from Collierville, Cordova, Germantown, Southaven and West Memphis. We offer free, convenient parking located in the Crosstown Concourse parking garage. TM TM Financing Available 901.252.3670 tearwell.com | [email protected] 901.252.3670 tearwell.com | [email protected] facebook.com/ *Financing options for LipiFlow are available tearwellcenter @TearWellCenter 1350 Concourse Avenue at Crosstown Concourse through a third party financing company. Your Dry Eye Relief Starts Now Meet Your Doctors This information packet marks the start of finding the optimal relief Arizona. In 2013, Dr. Grant joined Southern College of Optometry, where Whitney Hauser, OD your dry eyes need. If dry eye relief has eluded you, TearWell brings she currently serves as a Clinical Instructor in The Eye Center. She is is the Clinic Development Consultant of TearWell you new opportunities to treat your symptoms. a member of the Tennessee Public Health Association, Tennessee Advanced Dry Eye Treatment Center. Dr. Hauser Association of Optometric Physicians and the American Optometric graduated from The University of Tennessee at TearWell offers the expertise of three optometric physicians Association. known for their research and extensive experience in treating Knoxville with a bachelor’s degree in Biology. She ocular surface disease, including dry eye disease. TearWell obtained her Doctor of Optometry at Southern College of Optometry (SCO) with the academic distinction magna cum Kristina Haworth, OD focuses exclusively on dry eye treatment. laud and completed her residency in Primary Care through SCO and the serves as Associate Professor at Southern College VA Medical Center in Memphis. She was also a member of Beta Sigma of Optometry. She served as Assistant Professor Kappa Honor Society. at The Ohio State University from 2011-2015. “TearWell has given me Dr. Hauser was in private practice for 10 years where her concentration While she was at Ohio State she earned both an new hope in finding the was Dry Eye and Ocular Surface Disease management as well as surgical M.S. and Ph.D. in Vision Science. Before that, she pre and post-operative care. She is an active member of the American earned her O.D. from Southern California College of Optometry. Prior help I needed.” Optometric Association, Ocular Nutrition Society, the Association for to her academic career, Dr. Haworth was part of an interdisciplinary Research in Vision and Ophthalmology, the World Congress of Optometry ophthalmology and optometry practice for 7 years before opening her and Women of Vision. Dr. Hauser is also an avid runner and fitness own solo optometric practice in California. It’s never been a better time to take advantage of the innovative, enthusiast. At Southern College of Optometry, Dr. Haworth supervises clinicians diagnostic testing that allows TearWell to create a customized in The Eye Center and at the University Eye Center. She also conducts treatment for each patient. TearWell is the first treatment center research related to findings from her Ph.D. dissertation. ® Rachel Grant, OD in the Memphis area to offer LipiFlow, the only FDA-approved Dr. Haworth holds optometry licenses in California, Ohio, Oregon and treatment for dry eye disease. graduated from the University of Victoria, in British Tennessee. She is a Fellow of the American Academy of Optometry. Columbia, Canada. She obtained her Doctor Her research focus is in ocular surface and dry eye conditions. She has At TearWell, we’re committed to understanding your needs. We of Optometry at Southern California College of published manuscripts in peer-reviewed journals and has presented look forward to meeting you and building a relationship as we Optometry (SCCO) at Marshall B. Ketchum University some of her findings at national annual meetings of the American explore the best treatment options available for you. and completed her residency training in Primary Academy of Optometry and the Association for Research in Vision and Care and Ocular Disease at Hu Hu Kam Memorial Hospital in Sacaton, Ophthalmology (ARVO) through scientific papers and posters. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES I understand and acknowledge that in an attempt to protect the privacy of my identifi able health information, The Eye Center at Southern College of Optometry has established a Notice of Privacy Practices. This information details the use and disclosure of information contained in my personal medical records kept for the purposes of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the The Eye Center at Southern College of Optometry’s Notice of Privacy Practices has been made available to me while in the facility today. Should I choose to have a personal copy, one will be given to me at no charge. You can access this document at www.tec.sco.edu/patients/documents/GC-120A_notice_of_privacy_practices.pdf Patient Signature, if not a minor Date If patient is a minor, parent/legal guardian sign here Date If patient is a minor, agent for the Legal Custodian Date GC-120B 08/10 | Medical History Name: ___________________________________________________________ Date: _____________________ Email: ___________________________________________________________ Birth Date: ________________ Last Eye Exam (date): ________________ Last Eye Doctor (name): ____________________________________ Last Medical Exam (date): ____________ Last Medical Doctor (name): _________________________________ What is your eye problem/complaint today? Please describe this problem you are having as best as you can. ___________________________________________________________________________ ___________________________________________________________________________ Patient Ocular/Medical History Yes No Social History Yes No Glaucoma Do you smoke? Cataracts If YES, do you smoke every day? Macular Degeneration If NO, did you used to smoke? Eye Injury Do you use recreational drugs Retinal Disease Do you drink alcohol? Loss of Vision/Blindness Are you currently pregnant or nursing? Eye Turn/Strabismus What is your occupation? Lazy Eye/Amblyopia What are your hobbies? Eye Infection How many hours a day do you use a computer? Dry Eye What is your current
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