Your appointment will last between 1.5 and 2 hours and you will not be dilated or your vision affected in any way.

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Welcome to TearWell,

We are a unique clinical facility dedicated exclusively to the diagnosis and treatment of Dry Eye Syndrome. TearWell is located in the lobby of the Southern College of Optometry tower at 1245 Madison Ave. Memphis, TN. Free parking is readily available in front of the tower and The Eye Center.

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.

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

Clinical Coordinator 901.722.3263

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DRY EYE

RELIEF

1245 Madison Avenue | Memphis, TN 38104 | 901.722.3263 | tearwell.com

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This information packet marks the start of finding the optimal relief your dry eyes need. If dry eye relief has eluded you, TearWell brings you new opportunities to treat your symptoms.

TearWell offers the expertise of two optometric physicians known for their research and extensive experience in treating ocular surface disease, including dry eye disease. TearWell focuses exclusively on dry eye treatment.

“TearWell has given me

new hope in finding the

help I needed.”

It’s never been a better time to take advantage of the innovative, diagnostic testing that allows TearWell to create a customized treatment for each patient. TearWell is the first treatment center in the Memphis area to offer LipiFlow®

, the only FDA-approved treatment for dry eye disease.

At TearWell, we’re committed to understanding your needs. We look forward to meeting you and building a relationship as we explore the best treatment options available for you.

*Financing options for LipiFlow are available through a third party financing company.

Your Dry Eye Relief Starts Now

Financing

Available

901.722.3263

tearwell.com | info@tearwell.com

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Your Dry Eye Relief Starts Now

Alan G. Kabat, OD, FAAO

Dr. Alan Kabat is an honors graduate of Rutgers University and the Pennsylvania College of Optometry. He completed his optometric residency training at John F. Kennedy Memorial Hospital in Philadelphia. Following his education and several years in practice, Dr. Kabat joined the faculty at Nova Southeastern University College of Optometry in Fort Lauderdale, Florida. During his 20 years at NSU, he served as Director of Residency Programs, Chief of the Primary Care Service at The Eye Institute and also Director of the Dry Eye and Ocular Surface Disease Service at The Eye Institute.

In 2013, Dr. Kabat joined Southern College of Optometry, where he currently holds the rank of Professor. In addition to serving as Clinical Care Consultant for TearWell Advanced Dry Eye Treatment Center, he is a Staff Physician at The Eye Center in both the Advanced Care Ocular Disease Service and Adult Primary Care Service.

Dr. Kabat has built a reputation of clinical excellence and distinguished service in the area of optometric education. He is an internationally recognized expert in ocular disease management, with a primary interest in dry eye and related disorders of the ocular surface. Dr. Kabat has published well over 200 papers, book chapters and review articles in the optometric literature. Additionally, Dr. Kabat lectures regularly at optometric educational conferences in the United States and abroad.

Whitney Hauser, OD

is the Clinic Development Consultant of TearWell Advanced Dry Eye Treatment Center. Dr. Hauser graduated from The University of Tennessee at Knoxville with a bachelor’s degree in Biology. She obtained her Doctor of Optometry at Southern College of Optometry (SCO) with the academic distinction magna cum laud and completed her residency in Primary Care through SCO and the VA Medical Center in Memphis. She was also a member of Beta Sigma Kappa Honor Society.

Dr. Hauser was in private practice for 10 years where her concentration was Dry Eye and Ocular Surface Disease management as well as surgical pre and post-operative care. She is an active member of the American Optometric Association, Ocular Nutrition Society, the Association for Research in Vision and Ophthalmology, the World Congress of Optometry and Women of Vision. Dr. Hauser is also an avid runner and fitness enthusiast.

Rachel Grant, OD

Dr. Rachel Grant graduated from the University of Victoria, in British Columbia, Canada. She obtained her Doctor of Optometry at Southern California College of Optometry (SCCO) at Marshall B. Ketchum University and completed her residency training in Primary Care and Ocular Disease at Hu Hu Kam Memorial Hospital in Sacaton, Arizona. In 2013, Dr. Grant joined Southern College of Optometry, where she currently serves as a Clinical Instructor in The Eye Center. She is a member of the Tennessee Public Health Association, Tennessee Association of Optometric Physicians and the American Optometric Association.

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Making Your TearWell

Appointment

You’ve suffered from dry eyes long enough.

Take the first step in 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.

With the expertise of two of the leading

optometric physicians who have devoted

much of their career to treating dry eye

disease, TearWell additionally benefits from

its association with one of the nation’s leading

optometry colleges and clinical facilities.

Schedule your appointment today to begin

a consultation to explore the best treatment

option for you. Call

901.722.3263 or email

info@tearwell.com. You may also visit

TearWell.com to learn more.

Here’s how to visit us:

The TearWell Advanced Dry Eye Treatment Center’s primary location is open Monday-Friday from 8 am-5pm in the research suites of Southern College of Optometry in Memphis. Located in the 11-story tower at 1245 Madison Avenue, TearWell is a standalone treatment center exclusively dedicated to the treatment of Dry Eye Disease and dry eye symptoms.

TearWell is conveniently located with 15-25 minute drives from Collierville, Cordova, Germantown, South-aven and West Memphis. We offer free, convenient parking located directly in front of the SCO tower.

TearWell’s satellite office is located in East Memphis at Eye Specialty Group, 1458 W. Poplar Ave., Suite 101, in Collierville.

Appointments may be requested at this location for the 1st and 3rd Mondays of each month. Please specify which location you prefer when making your appointment.

901.722.3263

tearwell.com | info@tearwell.com

1245 Madison Avenue

at Southern College of Optometry

TEC Parking Lot Activity Center Parking Lot S C O T o w er P a rk in g L o t Auxiliary Parking Lot South Parking Lot UNION AVENUE MADISON AVENUE The Eye Center SCO Tower Activity Center BELLEVUE BOULEV ARD CLA YBROOK S TREET facebook.com/ tearwellcenter @TearWellCenter TM 10/15 SHEA RD . BAIL Y S TA TION FORES T HILL IRENE GERMANT O WN RD . BRA Y S TA TION RD . POPLAR AVENUE WINCHESTER HOUS TON LEVEE

BILL MORRIS/NONCONNAH PKWY. (TN 385)

COLLIERVILLE BAPTIST MEMORIAL HOSPITAL EYE SPECIALTY GROUP GERMANTOWN H

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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

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|

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.

___________________________________________________________________________

What is your preferred pharmacy? ________________________ Phone Number: ______________________ Do you have any allergies to medications? _______________________________________________________ Do you have environmental allergies? ___________________________________________________________

Patient Ocular/Medical History

Yes No

Glaucoma Cataracts Macular Degeneration Eye Injury Retinal Disease Loss of Vision/Blindness Eye Turn/Strabismus Lazy Eye/Amblyopia Eye Infection Dry Eye

High Blood Pressure/Hypertension Diabetes

Other Disease(s)/Prematurity Do you wear glasses?

Do you wear contact lenses?

If NO, would you like to?

Have you ever had a surgery on your eyes?

If YES, what was it? Why did you have it performed?

Family Ocular/Medical History

Yes No

Glaucoma Cataracts Macular Degeneration Eye Injury Retinal Disease Loss of Vision/Blindness Eye Turn/Strabismus Lazy Eye/Amblyopia Eye Infection Dry Eye

High Blood Pressure/Hypertension Diabetes

Other Disease(s)/Prematurity

Social History

Yes No

Do you smoke?

If YES, do you smoke every day? If NO, did you used to smoke?

Do you use recreational drugs Do you drink alcohol?

Are you currently pregnant or nursing? What is your occupation?

What are your hobbies?

How many hours a day do you use a computer? What is your current height?

What is your current weight?

Patient Review of Health

Do you currently have or ever had problems in the following areas? Yes No

Constitution(Fever, Weight Gain/Loss)

Cardiovascular/Vascular(Diabetes, High Blood Pressure, Stroke)

Ears, Nose, Throat, Mouth(Allergies, Sinus Congestion, Dryness)

Respiratory(Asthma, Bronchitis, Emphysema)

Gastrointestinal(Diarrhea, Constipation)

Genitourinary(Genitals, Kidney, Bladder Problems)

Musculoskeletal(Arthritis, Joint/Muscle Pain)

Integumentary(Skin Problems)

Neurological(Headaches, Migraines, Seizures)

Psychiatric(Mental/Emotional Problems)

Endocrine(Thyroid/Other Gland Problem)

Hematologic/Lymphatic(Anemia, Bleeding Problems)

Allergic/Immunologic(Allergy)

Medications

List all medications that you currently take (including over-the-counter, vitamins, supplements, oral contraceptives, etc.)

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|

Ocular Surface Disease Index

Everyone experiences some eye discomfort. But if your eyes frequently burn, itch, or feel gritty, you may be experiencing symptoms of Dry Eye Disease.

Please answer the questions below and fill in boxes in A,B,C,D and E.

Be sure to give the completed form to your Eye Care Professional BEFORE your exam.

Have you experienced any of the following During the last week?

A. Physical Symptoms

All of the _time Most of the _time Half of the _time Some of the _time None of the _time

1 Eyes that are sensitive to light 4 3 2 1 0 N/A

2 Eyes that feel gritty 4 3 2 1 0 N/A

3 Painful or sore eyes 4 3 2 1 0 N/A

4 Blurred vision 4 3 2 1 0 N/A

5 Poor vision 4 3 2 1 0 N/A

Subtotal score for answers 1 to 5

_A

Have problems with your eyes limited you in performing any of the following During the last week?

B. Daily Activities

All of the _time Most of the _time Half of the _time Some of the _time None of the _time

6 Reading 4 3 2 1 0 N/A

7 Driving at night 4 3 2 1 0 N/A

8 Working with a computer or _{bank machine (ATM)} 4 3 2 1 0 N/A

9 Watching TV 4 3 2 1 0 N/A

_B

Have your eyes felt uncomfortable in any of the following situations During the last week?

C. Environmental

Factors

All of the

time Most of the time Half of the time Some of the time None of the time

10 Windy conditions ₄ ₃ ₂ ₁ ₀ _N/A

11 Places or areas with low hu-_{midity (very dry)} 4 3 2 1 0 N/A

12 Areas that are air conditioned 4 3 2 1 0 N/A

_C

Add subtotals A,B, and C to obtain D _______ Total number of questions answered _______

Name ___________________________________ Date ____________________________________

TW-108 (08/14)

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|

Speed Questionnaire

First name _______________________________ Last name _______________________________ Date of birth ____________________ Gender q Male q Female Account# _________________

How FREQUENTLY do you experience the following dry eye symptoms?

Symptoms Never (0) Sometimes (1) Often (2) Constant (3)

Dryness, grittiness or scratchiness Soreness or irritation

Burning or watering Eye fatigue

How SEVERE are your dry eye symptoms?

Symptoms No Problems

(0) not perfect but Tolerable not uncomfortable (1) Uncomfortable irritating & interferes with my day (2) Bothersome irritating & interferes with my day (3) Intolerable unable to perform my daily tasks (4)

Dryness, grittiness or scratchiness Soreness or irritation

Burning or watering Eye fatigue

WHEN have you experienced these symptoms?

q Today q Within the last past 72 hours q Within the past 3 months

Symptoms Yes No

Do you have difficulty reading?

Do you have difficulty using a computer? Do you have difficulty driving?

Do you have difficulty watching television? Do you have difficulty wearing contact lenses? Do you have difficulty being outdoors?

Do your symptoms worsen throughout the day?

Do you use eye drops and/or ointment? q Yes q No

If yes, which drops do you use? How frequently do you use them? _______________________________ Have you been told that you have blepharitis or have you been treated for a stye?

Blephartis q Yes q No Stye q Yes q No

In what way is dry eye negatively impacting your life the most? ____________________________ _________________________________________________________________________________

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www.carecredit.com

_{* Subject to credit approval. See inside for details.}

The care you want.

With financing options

made easier.

*

Not all enrolled healthcare practices offer all special financing options, so please ask your provider to explain which ones are available for your purchase.

No Interest If Paid In Full Within 6, 12, 18 or 24 Months*

On qualifying purchases of $200 or more made with your CareCredit credit card account. Interest will be charged to your account from the purchase date if the promotional purchase is not paid in full within the promotional period. Purchases eligible for 6, 12 or 18 Month promotions: Minimum Monthly Payments required. Purchases eligible for 24 Month promotion: Fixed Monthly Payment required until paid in full and based on repayment over 24 months. Required monthly payments may or may not pay off purchase before end of promotional period.

*Offer applies only to single-receipt qualifying purchases. No interest will be charged on the promotional purchase if you pay the promotional purchase amount in full within the 6, 12, 18 or 24 month promotional period. If you do not, interest will be charged on the promotional purchase from the purchase date. If your purchase qualifies for a 24 month promotional offer, fixed monthly payments are required equal to 4.1667% of initial promotional purchase amount until promotion is paid in full. The fixed monthly payment will be rounded up to the next highest whole dollar and may be higher than the minimum payment that would be required if the purchase was a non-promotional purchase. For all other promotional offers, the regular minimum monthly payment terms of the account will apply. Regular account terms apply to non-promotional purchases and, after promotion ends, to promotional balance. For new accounts: Purchase APR is 26.99%; Minimum Interest Charge is $2. Existing cardholders should see their credit card agreement for their applicable terms. Subject to credit approval.

14.90% APR And Fixed Monthly Payments Required Until Paid In Full**

On qualifying purchases of $1,000 or more made with your CareCredit credit card account. Fixed monthly payment amount based on repayment over 24, 36, 48 or 60 month period. Purchases of $1,000 or more are eligible for a 24, 36 or 48 month offer and purchases of $2,500 or more are eligible for a 60 month offer.

**Interest will be charged on promotional purchases from the purchase date at a reduced 14.90% APR, and fixed monthly payments are required until promotion is paid in full and will be calculated as follows: on 24 month promotions – 4.8439% of initial promotional purchase amount; on 36 month promotions – 3.4616% of initial promotional purchase amount; on 48 month promotions – 2.7780% of initial promotional purchase amount; and on 60 month promotions – 2.3737% of initial promotional purchase amount. The fixed monthly payment will be rounded up to the next highest whole dollar and may be higher than the minimum payment that would be required if the purchase was a promotional purchase. Regular account terms apply to non-promotional purchases. For new accounts: Purchase APR is 26.99%; Minimum Interest Charge is $2. Existing cardholders should see their credit card agreement for their applicable terms. Subject to credit approval.

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CareCredit is here to help you get

the care you’re ready for.

CareCredit helps you get the refractive or other ophthalmic procedures you want now*_{– without delay.}

CareCredit gives you flexibility and convenience when managing your family’s out-of-pocket healthcare expenses. The CareCredit health, wellness and beauty credit card can be used as often as you want*_{at more}

than 165,000 enrolled healthcare practices for yourself, your family, even those other very special family members – your pets.

You can use it to pay for LASIK, cataract surgery, eyeglasses and contacts, prescription and non-prescription sunglasses, dental care, BOTOX® and fillers, laser treatments, skin care, and even trips to the veterinarian. You can also use it for insurance co-payments and deductibles.

Using CareCredit helps you reserve your cash and other credit cards for other expenses.

Get an answer right away.

Get started right away.

*

It’s easy to apply for CareCredit and you’ll receive an answer almost immediately. If you’re approved, you can schedule your procedure even before you get your card. That’s the whole idea – to help you get the care you want, right away.

BOTOX® is a registered trademark of Allergan, Inc.

No Interest If Paid In Full Within

6, 12, 18 or 24 Months

Special Financing Options

*

Available on qualifying purchases of $200

or more made with your CareCredit healthcare credit card account. Interest will be charged to your account from the purchase date if the promotional purchase is not paid in full within the promotional period. Minimum or fixed monthly payments required and may or may not pay off purchase before end of promotional period.

Reduced Interest (14.90% APR)

And Fixed Monthly Payments

Required Until Paid In Full

Special Financing Options

**

Available on qualifying purchases of $1,000 or more made with your CareCredit healthcare credit card account. Purchases of $1,000 or more are eligible for a 24, 36 or 48 month offer. Purchases of $2,500 or more are eligible for a 60 month offer. Fixed monthly payment amount is based on repayment over a 24, 36, 48 or 60 month period.

For Purchases Under $200:

Standard Terms

Your CareCredit healthcare credit card has standard terms for those smaller purchases that are under $200. Use it for things like contacts, dry eye treatment, co-payments and deductibles, teeth whitening products, skin care products or pet care supplies.

*/** Subject to credit approval. Please see the back page for more details on these Special Financing Options. Ask for details.

We give you

options you can’t

get with other

credit cards.

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^IMPORTANT INFORMATION ABOUT ESTIMATED MONTHLY PAYMENT OPTIONS: Monthly payments shown in this table should allow you to pay the associated total amount

financed in full within the promotional period if: (a) this amount is and will be the only balance on your account during the promotional period and (b) you make the monthly payment shown by the due date each month. Your total payments (cost) will equal the total amount financed.

IN ADDITION

For Optional Equal Monthly Payments: Payments shown in the table are equal to the total amount financed divided by the number of months in the promotional period and

are greater than the required minimum monthly payment that will be shown on your billing statement for this promotional purchase. If you have any additional balance on your

account, even paying each Optional Equal Monthly Payment may not pay off the total amount financed within the promotional period, and interest may be charged to your account from the purchase date.

For 14.90% APR and Fixed Monthly Payments: If you have any additional balance on your account, the monthly payments applicable to those balances will be added to this fixed

payment and may impact how payments are applied to this promotional purchase.

Not all enrolled healthcare practices offer all special financing options,

so please ask your provider to explain which ones are available for your purchase.

Estimated Monthly Payments for Special Financing Options

For purchases less than $200, Standard Terms apply. */** See back panel for details.

No Interest if Paid in Full Within

Promotional Period Financing Options* 14.90% APR and Fixed Monthly Payments Required Until Paid in Full Financing Options** For amounts from $200 & up For amounts from $1,000 & up For amounts from

$2,500 & up

Optional equal monthly payments could pay off amount financed

within promo period^

Estimated fixed monthly

payments Estimated fixed monthly payment includes interest^ Promotional

Period (Estimated Payoff Period)

6 Months 12 Months 18 Months 24 Months 24 Months 36 Months 48 Months 60 Months

Amount

Financed PaymentMonthly PaymentMonthly Monthly Payment PaymentMonthly PaymentMonthly Total Cost with Interest Monthly Payment Total Cost with Interest Monthly Payment Total Cost with Interest Monthly Payment Total Cost with Interest

$200 $34 $25 $25 $9 N/A N/A N/A N/A N/A N/A N/A N/A

$1,000 $167 $84 $56 $42 $49 $1,163 $35 $1,247 $28 $1,334 N/A N/A $2,000 $334 $167 $112 $84 $97 $2,326 $70 $2,493 $56 $2,667 N/A N/A $3,000 $500 $250 $167 $125 $146 $3,488 $104 $3,739 $84 $4,001 $72 $4,273 $4,000 $667 $334 $223 $167 $194 $4,651 $139 $4,985 $112 $5,334 $95 $5,697 $5,000 $834 $417 $278 $209 $243 $5,813 $174 $6,231 $139 $6,668 $119 $7,122 $6,000 $1,000 $500 $334 $250 $291 $6,976 $208 $7,478 $167 $8,001 $143 $8,546 $7,000 $1,167 $584 $389 $292 $340 $8,138 $243 $8,724 $195 $9,335 $167 $9,970 $8,000 $1,334 $667 $445 $334 $388 $9,301 $277 $9,970 $223 $10,668 $190 $11,394 Over

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One easy card.

And 165,000 places to use it.

More than 165,000 enrolled healthcare practices accept CareCredit, so your whole family can get the care they want and need – anytime. You can even use it for co-payments and deductibles.

CareCredit is the one credit card in

your wallet designed for one very important

thing: helping you manage your family’s

healthcare expenses. You can even use it

for kids who are away at college.

■ LASIK Surgery ■ Vision Exams ■ Eyeglasses and Contacts ■ Dental Care ■ Teeth Whitening ■ Braces ■ Veterinary Care ■ Cosmetic Procedures ■ Dermatology ■ Chiropractic Care ■ Hearing Aids

* Subject to credit approval.

www.carecredit.com

Simple and easy, from the

minute you apply.

*

Getting started with CareCredit is easy. Applying only takes a few minutes and you’ll get a decision almost immediately. You can apply whichever way is easiest for you:

Apply in person, right here, right now.

• Ask for an application; after you’ve filled it out and signed it, you’ll get a fast credit decision, usually within minutes.

Apply online or call 800-365-8295.

• Visit www.carecredit.com and complete the patient application.

• Or call us and we’ll walk you through it (note: must be 21 years or older to apply by phone).