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 Southgate MI 48195 1-800-403-0060

113 East Long Lake Rd Troy MI 48085

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 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

Demographics Form

PATIENT NAME HOME PHONE# WORK PHONE#

CELL PHONE# EMAIL

ADDRESS CITY STATE MI

ZIP

SEX AGE BIRTH DATE MARITAL STATUS S M D W

SOCIAL SECURITY NUMBER

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

□ Asian □ Black or African American

□ Native Hawaiian or Other Pacific Islander

Ethnicity: □ Hispanic □ Not Hispanic

Language Preference: □ English □ Other

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?

□ Patient/Family □ Google □ Internet

□ Insurance □ Location □ Family Doctor

□ Other________________________________

If referred by Doctor please add information here:

Name:

Address: City:

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 □ Previous Surgery □ Contact Lens □ Pain □ Double Vision □ Glaucoma □ Cataracts □ Macular Degeneration □ Dry Eyes □ Flashes □ Floaters 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

Respiratory □ Cough □ Congestion □ Wheezing □ Asthma Gastrointestinal □ Heartburn □ Nausea / Vomiting □ Jaundice / Hepatitus 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

Blood / Lymphnodes □ Easy Bruising □ Gums Bleed Easy

□ Prolonged Bleeding □ Heavy Aspirin Use

MusculoSkeletal □ Stiffness □ Arthritis □ Joint Pain / Swelling Skin □ Rash / Sores □ Lesions □ Hives / Eczema Neurological □ Seizures □ Weakness / Paralysis □ Numbness □ Tremors Immunologic □ Hives □ Itching □ Runny Nose □ 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)

The Future of LaserVision Correction is Here

Am I a Candidate?

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!

• 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.

www.castlemaneyecenter.com

PH: 800.403.0060 • F: 734.283.2720800-403-0060

Southgate, MI 48195

Changing Lives Through Vision13080 Eureka Road

Castleman Eye Center

*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

Castleman Eye Center

Castleman Eye CenterChanging Lives Through Vision

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 theWaveScan® 3-D map. Through a series of tests, this toolmaps out all the imperfections in your vision so yourpersonalized vision correction plan can be formulated forthe Advanced CustomVue vision correction laser.

Step 2: Intralase™ Laser

Although complications are rare, in conventional LASIKthe majority occur during the creation of the flap with themicrokeratome blade. The Intralase™ Laser used in iLASIK™

eliminates these types of complications. The flap, createdwith the Intralase™ Laser, is a thinner, more precise flap thatallows 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 thecustom laser treatment on your cornea. The WaveScan®map provides the surgeon and the laser’s computer theinformation needed to reshape your cornea for your bestvision possible. The cool beam of light treats the corneapainlessly 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.

© 2008 #35739 Doctordirect™

New NASA guidelines specify that only

iLASIK™ may be performed on its

astronauts using precise measurement

and wavefront-guided lasers.

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