□ Eval □ Meas date _ __ _____ time _________ Location: □ Omaha □ Sioux City
Surgery date ________ _ Arrival time ________ SX time __ __ Location: □ Omaha □ Sioux City
4909 S. 118th St. Omaha, NE 68137
( 402) 397-2010 ·(800) 433-2015 ·(402) 397-8439 fax ·www.nebraskaeye.com
Date: _________________________ Pt. ID: __________________
Name: Birthdate: / / _ Age: ______
Address: _______ City: _ State: Zip: _______
Home phone: ____________________ Work / Cell Phone: ______________ Sex: M F
Who is your current eye doctor? ______________________________________________
Do you currently wear contact lenses? Yes* / No *If “Yes”: Rigid OR Soft
How did you hear about Nebraska Laser Eye Associates?
OD WOM Radio Newspaper Television Mailing Internet Walk-in Other Price: _
________________________________________ Folder sent:_ ___
Patient Employer: __________________ __ Patient Occupation: ___________ ___ ___
Email address: ________________________ Spouse Name: ________________________
Personal Ocular History
Personal Medical History
Do you have? Yes No Do you have? Yes No
Cataracts Diabetes
Glaucoma Heart disease
Eye Injury Autoimmune Disease
Lazy Eye Arthritis
Keratoconus HIV
Retinal Disease Depression
Dry Eyes Currently Pregnant / Nursing
Other eye surgery Latex Allergy
Bleeding tendency
Please list any:
allergies to medications:______________________________________________________
previous surgeries: __________________________________________________________
diseases or medical conditions:________________________________________________
medications you are currently taking:__________________________________________
___________________________________________________________________________
PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. The Notice contains a Patient Rights section describing your rights under the law.
You have the right to review our Notice before signing this Consent. The terms of our Notice may change.
If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or
disclosed for treatment, payment or health care operations. We are not required to agree to this restriction,
but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for
treatment, payment and health care operations. You have the right to revoke this Consent, in writing,
signed by you. However, such a revocation shall not affect any disclosures we have already made in
reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care
operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this
Notice.
The Practice reserves the right to change the Notice of Privacy Policies.
The patient has the right to restrict the uses of their information but the Practice does not have to
agree to those restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then
cease.
The Practice may condition treatment upon execution of this Consent.
This Consent was signed by: ___________________________________________________
Patient or Patient Representative
___________________________________________________
Date
In front of:
___________________________________________________
4909 S. 118th St., Omaha, NE 68137 402-397-2010 · 800-433-2015 · 402-397-8439 fax
LASIK FOLLOW-UP RELEASE
Patient Name Date
My surgeon, Dr. Mark Johnston, has given me, and I have read, the instructions regarding proper eye care
following Laser Vision Correction (LASIK or PRK) surgery.
I have informed Dr. Johnston that it would be more convenient for me to have my post-operative care
performed by my own eye doctor, Dr. ___________________________. I have discussed this with my eye doctor
and he/she is willing to perform these services in conjunction with my surgeon and will keep Dr. Johnston
informed of my progress.
I understand that I am to contact Dr. Johnston at any time with any questions or problems. I understand
that if I should choose to return to Dr. Johnston for the remainder of my post-operative care, I may do so at
any time.
I am aware that a percentage of the LASIK fee collected on the day of surgery may be forwarded to my
referring eye doctor for their pre- and post-operative care.
Patient Signature Date
A PATIENT’S BILL OF RIGHTS
At Johnston Ambulatory Surgery Center, LLC (JASC) we believe our patients have certain rights when visiting our office as well as certain responsibilities to our office. This is asummary of these rights and responsibilities: As our patient, you have the right to
:
1. Respectful and safe care by competent personnel;
2. Be informed of patient rights during the admission process; 3. Be informed in advance about care, treatment and related risks;
4. Make informed decisions regarding care and treatment and to receive information necessary to make those decisions;
5. Refuse care, participation in experimental research and treatment and to be informed of the medical consequences of refusing such;
6. Every consideration of his/her privacy concerning his/her medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly involved in his/her care must have permission of the patient to be present;
7. Expect that within its capacity, this accredited ambulatory surgery facility must provide evaluation service and/or referral as indicated by the urgency of the case. When medically permissible, a patient may be
transferred to another facility only after he/she has received complete information and explanation concerning the needs for and alternatives to such a transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer;
8. Obtain information as to any relationship of this facility to other health care and educational institutions insofar as his/her care is concerned. The patient has the right to obtain information as to the existence of any
professional relationships among individuals, by name, who are treating him/her;
9. Expect reasonable continuity of care. He/she has the right to know in advance what appointment times and physicians are available and where. The patient has the right to expect that this facility will provide a mechanism whereby he/she is informed by his physician of the Patient’s continuing health care requirements following discharge;
10. Be advised in advance of the estimated fees related to your care and payment accommodations; 11. Be free from abuse, neglect and harassment;
12. Receive health services without discrimination;
13. Voice complaints and grievances without discrimination or reprisal and have those complaints and grievances addressed.
14. Receive treatment in a smoke free environment.
You have the responsibility to
:
1. Provide complete and accurate information about your past illnesses, medications, allergies and current health status.
2. Follow the pre-operative and post-operative instructions you will receive from the staff of JASC. 3. Cooperate with the treatments and nursing care provided once you understand the purpose. 4. Assure that the financial obligations for care are fulfilled as promptly as possible
If you have any questions, suggestions, complaints or grievances please contact
Jennifer Fischer, RN, BSN Mark Johnston, MD (402)397-2010 (402)397-2010
Nebraska Health and Human Services Medicare Ombudsman (402)471-031 www.medicare.gov/Ombudsman/activities.asp
Associates
Ambulatory Surgery Center
Is owned and operated by: Is owned and operated by:Mark Johnston MD PC Johnston Ambulatory Surgery Center LLC Mark E Johnston MD FRCSC Mark Johnston MD FRCSC
John G Goertz OD FAAO For your convenience, private pay patients will pay only Mark Johnston MD PC.
Your fees will then be disbursed, according to usual and customary fees, to the surgeon, your regular eye doctor, and the surgery center.
Medicare and certain insurance plans require that a separate bill be sent by the surgeon, your own eye doctor and the surgery center. If you have any questions concerning your billing, please ask our staff for assistance.
On the reverse is a copy of our Patient Bill of rights.
Should you have any complaints or specific concerns which you would like to have addressed, please notify the staff. You may also note these concerns on the patient questionnaire you receive at the time of surgery.
Should you wish to make a formal written complaint, please note that we have policies in place to assure that these receive serious consideration. Please address these to our Office Manager. Our staff would be happy to assist you in preparing such a written grievance. You should expect to receive a written reply within fourteen days of our receipt of your written complaint.
Advance Directive Policy
To comply with state law, during the registration process, you will be asked if you have an advance directive. Please bring a copy if you have one. If you do not have an advance directive and would like further information please call us at 402-397-2010. Upon request we will mail information regarding advance directives or will have it available to you at registration.
Physician Ownership Notice
The physician who is rendering services may have an ownership interest in Nebraska Laser Eye Associates. During the scheduling process, the physician's representative will give you the option to be treated at alternate facilities. If you wish to be treated at another facility please notify your physician's office.
I acknowledge that I was informed in writing of my patient rights, advance directive policy, and physician ownership notice, prior to the date of my procedure.
___________________________________________ _______________
Informed Consent for
Laser Assisted In-Situ Keratomileusis (LASIK)
Introduction
You are entitled to be informed about the proposed procedure, including the risks of the procedure and alternatives to it. Please read this document thoroughly and discuss the content with your physician so that all of your questions are answered to your satisfaction.
By signing this form I acknowledge and I understand the following:
1. This consent is incomplete as it is impossible to list and discuss all possible complications and consequences remotely possible with LASIK, or any other surgery, within the context of this form.
2. The procedure to be performed on my eye is called Laser Assisted In-Situ Keratomileusis (LASIK). The procedure involves surgically creating a flap of corneal tissue and treating the undersurface with an excimer laser. The flap of tissue is repositioned over this treated area. No sutures are required. This procedure will create a new corneal contour, thus decreasing the amount of nearsightedness, farsightedness, or astigmatism. 3. The objective of LASIK is to reduce or eliminate nearsightedness, farsightedness, or astigmatism.
4. It is not necessary to have LASIK. It is purely an elective procedure. 5. Alternative to LASIK include:
a. Spectacles (glasses) b. Contact lenses
c. Photorefractive keratectomy (PRK)
6. While many people have benefited from LASIK, some people have been disappointed by the results. A few have experienced persistent complications from having had LASIK.
7. Having LASIK does not necessarily mean total freedom from corrective lenses (spectacles or contact lenses), and there is a good chance I will need to wear some sort of corrective lenses in the future. If bifocals or reading glasses are presently required, a reading prescription may still be required after this surgical procedure.
Risks of Laser Assisted In-Situ Keratomileusis
Vision Threatening Complications. Although unlikely, there is a possibility that a loss of some or all useful vision
will occur as a result of the following:
a. Infection (internal or external) that cannot be controlled by antibiotics or other means.
b. Irregular healing of the cornea that could result in a distorted corneal surface so that distorted vision or ghosting occurs. This may not be correctable by spectacles or contact lenses.
c. Haze or scar on the cornea or under the flap.
d. Surgery may weaken the cornea, allowing a gradual development of irregularity of the surface requiring contact lenses and/ or other treatment.
e. After retreatment, the vision may not be correctable by spectacles or contact lenses to a level equal to preoperative vision.
f. Malfunction of the microkeratome or laser may require that the procedure be stopped before completion. g. Occlusion of a blood vessel caused by increasing the pressure within the eye during the procedure that
could also cause loss of some, or all, of the visual field. h. Displacement or folds of the flap requiring repositioning. i. Debris or tissue under the flap requiring removal.
j. Superficial scratching from the microkeratome may require a temporary bandage contact lens
Non-Vision Threatening Complications. It is expected that at least some of the following will occur:
a. Farsightedness. Some hyperopia may remain after LASIK. Alternatively, overcorrection may occur resulting in a residual nearsightedness after surgery. If the surgeon feels any further enhancement would be unwise, spectacles or contact lenses may be required.
b. Nearsightedness. Some myopia may remain after LASIK. Alternatively, overcorrection may occur resulting in residual farsightedness after surgery. If the surgeon feels any further enhancement would be unwise, spectacles or contact lenses may be required.
c. Contact lens intolerance. Regardless of success with contact lenses prior to surgery, there is a possibility that the eye will not tolerate contact lenses comfortably after the surgery.
d. Increases sensitivity to light. This tends to disappear after a few weeks, or possibly months. It is possible this will remain permanently.
e. Decreased vision in artificial or dim light. This may be permanent in some cases.
f. Starburst or halo around lights at night. This effect tends to diminish after the first few months, but some element can be permanent. Occasionally, patients have severe enough persisting problems to make them feel insecure driving at night.
g. There may be pain, particularly during the first 48 hours.
h. Although a double-checking system is in place, the wrong data may be entered into the laser which could result in an undercorrection or overcorrection.
By signing below, I agree that:
1. I have received no guarantee as to the success of my particular case.
2. I may be given a sedative at the time of surgery. I agree to arrange for someone to drive me home after my procedure, and to refrain from driving myself until I am comfortable with my vision.
3. As in all surgery, there is the possibility of other complications due to anesthesia, drug reaction, or other factors that involve other parts of the body. These complications rarely occur.
4. I understand that, as well as the surgeon, care will be provided by other health care professionals, including an assistant surgeon, as indicated. Professional personnel, students and product
representatives may be present in the operating room during surgery, at the discretion of the surgeon and the surgery center, for education and teaching purposes.
5. If my surgery is recorded, I give permission for its use in research and teaching.
6. The procedure has been explained to me in terms that I can understand. I have had the opportunity to ask all the questions I had regarding the procedure, and they have been answered to my satisfaction.
The decision to undergo the laser assisted in-situ keratomileusis (LASIK) procedure has been my own and has been made without duress of any kind.
________________________________ __________________________ ____________
Patient Name Patient Signature Date
________________________________ __________________________ ____________
Physician Signature Witness Signature Date
PLEASE WATCH CONSENT VIDEO AND COMPLETE QUESTIONNAIRE.
Print your name:__________________________________ Date:___________________________
QUESTIONS ON PREPARING FOR LASIK SURGERY VIDEO 2005, Patient Education Concepts, Inc.
The following questions cover important information contained in the video presentation. Please circle the answer you feel most correct. If you need more time to answer a question that the video presentation provides, skip that question and return to it when the program is over. Once you have completed the questions, compare your answers to those found at the bottom of the page.
1. TRUE or FALSE: LASIK will permanently change the shape of your cornea.
2. TRUE or FALSE: There are no guarantees as to exactly how well you will see after the procedure.
3. TRUE or FALSE: You may experience side effects such as haze, glare, halos, light sensitivity, and dryness of the eyes that may not go away completely.
4. TRUE or FALSE: All eyes are capable of seeing 20/20 or better. 5. TRUE or FALSE: After the surgery, follow-up visits are not important.
6. TRUE or FALSE: There is the possibility that another operation may be necessary after the initial procedure to obtain the best level of vision correction.
7. TRUE or FALSE: It is possible that you might still need to wear glasses or contacts, or that LASIK could cause loss of vision.
8. TRUE or FALSE: You may experience mild to moderate discomfort for several days after the procedure. 9. TRUE or FALSE: LASIK will eliminate your need for reading glasses when you are over 40 years of age,
or presbyopic.
10. TRUE or FALSE: The program that I watched covered all risks, side effects, and complications that could possibly occur either now or in the future with LASIK.
Use this space to write any questions or concerns you wish to ask your doctor or a staff member:
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _______________
ANSWERS:
1. TRUE: LASIK will permanently change the shape of your cornea.
2. TRUE: There are no guarantees as to exactly how well you will see after the procedure.
3. TRUE: You may experience side effects such as haze, glare, halos, light sensitivity, and dryness of the eyes that may not go away completely.
4. FALSE: Not all eyes are capable of seeing 20/20 or better. 5. FALSE: After the surgery, follow-up visits are very important.
6. TRUE: There is the possibility that another operation may be necessary after the initial procedure to obtain the best level of vision correction.
7. TRUE: It is possible that you might still need to wear glasses or contacts, or that LASIK could cause loss of vision.
8. TRUE: You may experience mild to moderate discomfort for several days after the procedure.
9. FALSE: LASIK will not eliminate your need for reading glasses when you are over 40 years of age, or presbyopic, unless you have the monovision or blended vision procedure.
10. FALSE: The program that I watched did not cover all risks, side effects, and complications that could possibly occur either now or in the future with LASIK.
Signature of patient:___________________________________ Date: _______________________________
