Lasik Exam Information Lasik Procedure Information

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:______

13080 Eureka Rd 113 East Long Lake Rd Southgate MI 48195 Troy MI 48085 1-800-403-0060

u:CECLASIK:PROCEDUREFEEINFO

Snigdha Singh, M.D. James R. Valice, M.D. Tiffany Humes, O.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 at other centers 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) Top 10 Doctor in Michigan Award 2014 and the Patient’s Choice Award for 2012- 2014, 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 113 E. Long Lake Rd Southgate MI 48195 Troy, MI 48085 Tel: (734) 283-0500 Tel: (248) 813-0099 Fax: (734) 283-2720 Fax: (248) 813-0210 Demographics Form

PATIENT NAME HOME PHONE# WORK PHONE#

CELL PHONE# EMAIL

ADDRESS CITY STATE ZIP

MI SEX AGE BIRTH DATE MARITAL STATUS 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 □ American Indian or Alaska Native Ethnicity: □ Hispanic □ Not Hispanic □ Asian □ Black or African American Language Preference: □ English □ Other

□ Native Hawaiian or Other Pacific Islander EMPLOYER OCCUPATION

SPOUSE NAME SPOUSE’S EMPLOYER

EMERGENCY CONTACT: ( For office use only: remember to add to Practice Partner)

NAME: PHONE: MEDICAL INSURANCE INFORMATION Primary: Subscriber Name/Birthdate:

Secondary: Subscriber Name/Birthdate:

Tertiary: Subscriber Name/Birthdate:

VISION INSURANCE Primary Secondary

How were you referred to us? If referred by Doctor please add information here: □ Patient/Family □ Google □ Internet Name:

□ Insurance □ Location □ Family Doctor Address: City:

□ Other______Phone: Family Doctor: Address: City: Zip:

Phone:

Pharmacy Name: Address: City: Zip: Phone:

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---

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 Respiratory Blood / Lymphnodes □ Previous Surgery □ Cough □ Easy Bruising □ Contact Lens □ Congestion □ Gums Bleed Easy □ Pain □ Wheezing □ Prolonged Bleeding □ Double Vision □ Asthma □ Heavy Aspirin Use □ Glaucoma □ Cataracts MusculoSkeletal □ Macular Degeneration Gastrointestinal □ Stiffness □ Dry Eyes □ Heartburn □ Arthritis □ Flashes □ Nausea / Vomiting □ Joint Pain / Swelling □ Floaters □ Jaundice / Hepatitus

Skin Ear, Nose, and Throat Genito-Urinary □ Rash / Sores □ Hard of Hearing □ Pain / Difficulty □ Lesions □ Ringing in Ears □ Blood in Urine □ Hives / Eczema □ Vertigo □ History of Kidney Stones □ History of STD’s Cardiovascular □ Chest Pain Neurological □ Dizziness Psychiatric □ Seizures □ Fainting Spells □ Anxiety / Depression □ Weakness / Paralysis □ Shortness of Breath □ Mood Swings □ Numbness □ Irregular Heart Beat □ Difficulty Sleeping □ Tremors □ Difficulty Lying Flat Endocrine Constitutional □ Increased Thirst Immunologic □ Fatigue / Weakness □ Increased Hunger □ Hives □ Fever □ Increased Urination □ Itching □ Weight Gain / Loss □ Increased Sweating □ Runny Nose □ Fingernail Changes □ Sinus Pressure

Dry Eye Survey

_____ Fluctuation in vision ______Redness ______Film over vision ______Burning

_____ Tired Eyes ______Watery Eyes ______Feeling of sand or grit in eye(s)

Page 3 Castleman Eye Center

Directions to Our Offices

Southgate Office 13080 Eureka Road, Southgate, MI, 48195 (734)283-0500

Directions: From Telegraph (US 24) North/South: Take Telegraph to Eureka Road east. Get in left lane to make the turn-around to go west on Eureka Road. Take Eureka Road East turn Left at 13080 Eureka Road (which is just before Fort St. across the street from Arby's restaurant).

Coming from the North: Take I-75 to the Eureka Road exit (Exit #36). Turn left on Eureka east. Take Eureka Road East turn Left at 13080 Eureka Road (which is just before Fort St. across the street from Arby's restaurant).

Coming from the South: Take I-75 to the Eureka Road exit (Exit #36). Turn right on Eureka. Take Eureka Road East turn Left at 13080 Eureka Road (which is just before Fort St. across the street from Arby's restaurant).

From I-275 North/South: Take I-275 to Eureka Road (Exit #15). Turn right/left (east) on Eureka Road and go approximately 15 miles. Turn Left at 13080 Eureka Road (which is just before Fort St. across the street from Arby's restaurant).

Troy Office Address: 113 East Long Lake Road, Troy, MI 48085

Directions: From: I-75 North/South Take the Big Beaver road exit and travel east to Livernois. On Livernois, travel north to E. Long Lake Road. We are located on the north east corner of the E. Long Lake/Livernois intersection. Look for the Sunset Plaza/CVS where “Castleman Eye Center” is prominently displayed on our office.

From I-75 North/South (Alternate Route): Take Rochester Rd. North to E. Long Lake. Stay in the right lane because you will have to turn right at E. Long Lake, make a Michigan left and go west on E. Long Lake Road. Look for the Sunset Plaza/CVS on the right just before the actual Livernois/E. Long Lake intersection. “Castleman Eye Center” is prominently displayed on our office.

lmgEyeCenter(Rev10.09) Castleman Eye Center Am I a Candidate? 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 The Future of Laser flap creator, and the wide range of vision imperfections Vision Correction is Here that the FDA-approved treatment laser can correct, more people than ever before are excellent candidates for laser *FREE LASIK Consultation *0% Financing for 2 Years vision correction. *All Inclusive Pricing-No Hidden Fees *Vitals Patient's Choice Award 2012 If you answer “true” to all the following criteria, it’s time *Over 9000 Procedures Performed for you to schedule an evaluation with your iLASIK ™ *LASIK Discount Program for Vision Plans surgeon today! *Over 40 Years in Practice

• 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 Castleman Eye Center 13080 Eureka Road Changing Lives Through Vision Southgate, MI 48195 800-403-0060 PH: 800.403.0060 • F: 734.283.2720 www.castlemaneyecenter.com Truly Customized All-Laser LASIK What’s The Next Step?

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

a Start care immediately a Pay over time with low monthly payments a For yourself and your family a Two Types of Promotional Plans Available:

No Interest if Paid in Full within 6, 12 or 18 Months † On purchases with your CareCredit card. Not all promotional plans are available in all offices. Interest will be charged to your account from the purchase date if the promotional balance, including optional charges, is not paid in full within 6, 12 or 18 months or if you make a late payment. Minimum Monthly Payments Required. or 14.90% APR & Fixed Minimum Monthly Payments for 24, 36, 48 or 60 Months † † On Purchases of $1,000 or more (24, 36 or 48 months) or $2,500 or more (60 months) with your CareCredit card. Accounts at Penalty APR ineligible for reduced APR. Fixed Minimum Monthly Payments Required. Penalty APR may apply if you make a late payment.

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182-077-00 Revision Date: 11/15/2010 DATE OF PRINTING: 9/10 For Providers: (800) 859-9975 For Patients/Clients: (800) 365-8295 APPLICATION AND CREDIT CARD AGREEMENT A credit service of GE Money Bank Submit by internet: carecredit.com

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2. CO-APPLICANT INFORMATION: (COMPLETE ONLY IF CO-APPLICANT REQUESTING A CARECREDIT CREDIT CARD) Name (First-Middle-Last) Please Print Date of Birth Social Security Number Home Phone Number

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Interest Rates and Interest Charges

Annual Percentage Rate (APR) for Purchases and 26.99% Balance Transfers

APR for Cash Advances 29.99%

Penalty APR and When 29.99% it Applies This APR may be applied to your Account if you make a late payment.

How Long Will the Penalty APR Apply? If your APRs are increased for this reason, the Penalty APR will apply until you make six consecutive minimum payments when due. Paying Interest Your due date is at least 23 days after the close of each billing cycle. We will not charge you any interest on purchases if you pay your entire balance by the due date each month. We will begin charging interest on cash advances and balance transfers on the transaction date.

Minimum Interest Charge If you are charged interest, the charge will be no less than $2.

For Credit Card Tips from To learn more about factors to consider when applying for or using a credit the Federal Reserve Board card, visit the website of the Federal Reserve Board at http://www.federalreserve.gov/creditcard.

Fees

Transaction Fees • Balance Transfer Either $5 or 4% of the amount of each transfer, whichever is greater. • Cash Advance Either $5 or 4% of the amount of each cash advance, whichever is greater.

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