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Dear Patient,
Congratulations on the purchase of your LivingSocial voucher for CustomVue™ LASIK surgery
with Dr. Frank Owczarek at Eye Care of Delaware! You have taken the first step to enhancing your vision
and we are excited for you.
Listed below is some helpful information to prepare you for your consultation:

Plan to spend approximately 2 hours at our office for your comprehensive consultation,
examination, testing, scheduling, and paperwork. If you need to reschedule, kindly give
a minimum of 24 hours notice.

Prior to your consultation you must discontinue wearing your contact lenses for the
following amount of time:
● 2 weeks for soft contact lenses
● 6 weeks for hard contact lenses

Your eyes will be dilated for this exam. If you are not comfortable driving after a dilated
exam, a driver is recommended.

Please bring the following with you:
 Eyeglasses
 Completed patient registration form and refractive surgery questionnaire
 LivingSocial voucher
Enclosed in this packet you will also find the consent for CustomVue LASIK surgery. Please take
some time to review it prior to your appointment and make a note of any questions you may have.
If you would like to learn more about Dr. Owczarek and answers to frequently asked questions
about LASIK, please visit our website at eyecareofdelaware.com and click on vision correction. We look
forward to meeting you and hope that we can help you see things differently!
Sincerely,
Refractive Surgical Team
4102 Ogletown-Stanton Road, Suite 1 ● Newark, Delaware 19713-4183 ● (302) 454-8800 ● Fax (302) 454-8801 ● eyecareofdelaware.com
Rev. 2/21/12
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Patient Registration Form
Today’s Date_________________________
Name___________________________________________________  M  F
Date of Birth________________
Address________________________________________________________________________________________
City________________________________________________State_______________Zip______________________
Home Phone (________)______________________ Work Phone (________)_____________________ext_________
Cell Phone (________)________________________ Email Address________________________________________
The best way to contact me is:  Home Phone  Work Phone
Check appropriate box:
 Single
 Married
 Cell Phone
 Widowed
 Separated
 Divorced
Occupation______________________________________________Employer________________________________
Name of regular eye doctor________________________________ Did he/she tell you about us?
 Yes
 No
Date of last eye exam_______________________ Name of medical doctor__________________________________
Whom may we thank for referring you? Please be specific and check all sources that apply.
 Friend/Patient (list name) ____________________________  Doctor__________________________________
 Internet Search
 Newspaper
 Publication____________________
 Radio/TV _______________
Person to contact in case of emergency_______________________________ Phone__________________________
Medical Insurance Information
Medicare ID#___________________________________Delaware Medicaid ID#_______________________________
For other primary or supplemental insurance, please complete the following:
Name of Insured_____________________________________ Relationship to Patient__________________________
Cardholder’s SSN#____________________________________Cardholder’s Date of Birth________________________
Insurance Company_____________________________ID#__________________________Group#________________
If your insurance company requires a referral, it is your responsibility to obtain it prior to your appointment.
Eye Care of Delaware Refractive Surgery Questionnaire
Name:
Appt. Date:
Daytime Phone Number:
Current Age:
Have you ever been screened for refractive surgery?
Yes
No
If yes, were you told you were a good candidate?
Do you wear?: (check all that apply)
Soft Contact Lenses
Gas Permeable Hard Lenses
Glasses
If you wear contact lenses, when was the last time you wore them:
If you wear contact lenses, have you had any problems?
No
Yes, please explain
Who is your eye doctor?:
Date of last eye exam:
Medical History
Have you had any prior eye surgery?
No
Yes
Have you had any eye problems? (check all that apply)
Dry Eyes
Other:
Cataracts
Retinal
Glaucoma
Please list all medical conditions:
High Blood Pressure
Diabetes
Autoimmune Disease
Pregnant or Nursing
List any medications, eye drops, herbal supplements, and vitamins you are currently taking:
List any drug allergies you may have:
I have no known drug allergies
What are your expectations from refractive surgery?
Notes/Questions you have for the doctor:
Latex allergy
Patient Name:________________________________________________
PRIVACY AUTHORIZATION NOTICE
I have read the Eye Care of Delaware, LLC Privacy Authorization Notice and by signing this form consent to Eye
Care of Delaware’s use and disclosure of protected health information. I authorize the release of information
to the following person(s):
Name
Relationship
________________________________________________
__________________________
________________________________________________
__________________________
________________________________________________
__________________________
PATIENT CONSENT FOR MEDICAL RECORDS MAINTENANCE
I have read the Eye Care of Delaware, LLC Medical Records Maintenance Policy and by signing this form
consent to this arrangement.
EYE CARE OF DELAWARE, LLC OFFICE POLICY
I have read the Eye Care of Delaware, LLC Office and Financial Policy and by signing this form consent to the
terms.
Signature: ___________________________________________
Date: _______________
PATIENT AUTHORIZATION ASSIGNMENT OF MEDICARE/MEDICAID BENEFITS
I request that payment of authorized Medicare/Medicaid benefits be made on my behalf to any physician utilizing the
Eye Care of Delaware and/or Cataract and Laser Center for any service furnished. I authorize any holder of medical
information about me to release to the Centers for Medicare & Medicaid Service (CMS) and its agents any information
needed to determine these benefits payable for related services. In Medicare/Medicaid assigned cases, the provider
agrees to accept the charge determination of the Medicare/Medicaid carrier and I am responsible for the deductible,
co-insurance and/or the 20% Medicare does not pay, and for any non-covered services.
My signature below further verifies that I have not joined an HMO or other entity in which my Medicare benefits have
been relinquished.
Signature: ___________________________________________
Date: _______________
COMMERCIAL/HMO/BLUE SHIELD/SECONDARY INSURANCE
I request that the payment of authorized benefits be made either by me or on my behalf to any physician utilizing the Eye
Care of Delaware and/or Cataract and Laser Center, for services provided to me. I authorize any holder of medical
information about me to release it to my insurer, or any information needed to determine these benefits payable for
related services. I am responsible for any insurance deductible, co-insurance, non-covered services and exclusion of
benefits. It is my responsibility to obtain any referrals required for services. If a referral was required and not obtained I
will be responsible to pay for the services received.
This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is considered valid
as the original.
Signature: ___________________________________________
Rev. 2/12
Date: _______________
CATARACT AND LASER CENTER, LLC
Consent for the use of the Excimer Laser for Performing
Photorefractive Keratectomy (PRK) / Laser In Situ Keratomileusis (LASIK)/ CustomVue LASIK (circle one)
You are entitled to be informed about the proposed PRK/LASIK/CustomVue LASIK treatment for myopia
(nearsightedness), hyperopia (farsightedness), either with or without astigmatism or mixed astigmatism,
including the risks of the treatment and the alternatives. Please read this document thoroughly and discuss the
content with your doctor, so that all of your questions are answered to your satisfaction.
This information is provided, so that you can make an informed decision regarding the use of the excimer laser
and microkeratome - the instrument used to create a corneal flap -- to treat your myopia, hyperopia, either with
or without astigmatism or mixed astigmatism.
Photorefractive Keratectomy (PRK) uses the excimer laser, which produces an intense beam of light that
removes the outer layer of corneal (eye) tissue.
Laser in situ Keratomileusis (LASIK) is a procedure that uses a microkeratome to create a corneal flap on the
surface of the eye to access the middle layer of the cornea to apply the excimer laser to thereby remove the
corneal tissue.
CustomVue LASIK is a procedure that uses a microkeratome to create a corneal flap on the surface of the eye
to access the middle layer of the cornea to apply the excimer laser, guided by the wavescan measurement, to
thereby remove the corneal tissue.
Due to the elective nature of your procedure, the facility declines to carry out instructions as set forth in any
advance directives. I consent to the administration of anesthesia and the use of such anesthetics or medications
as may be deemed advisable, including:
___ Topical Anesthesia: Potential risks may include redness, stinging, burning or rash.
___ Local Anesthetics Block: Potential risks may include allergic reaction, low or high blood pressure, rapid or
slow heart rate.
I authorize Cataract and Laser Center (CLC) to submit for pathology exam or to dispose of any specimens,
tissues or parts taken from my body during the course of this operation for procedure. I understand and give
consent for observers for medical education or my personal assistance to be present during my procedure.
I authorize CLC to use my medical information without my name for tracking, benchmarking and quality
assurance purposes.
PATIENT STATEMENT
I have myopia, hyperopia, either with or without astigmatism or mixed astigmatism, which requires me to wear
corrective lenses in order to see clearly for my daily activities. I have been clearly informed of the alternatives
including eyeglasses, contact lenses and other types of refractive surgery.
I have decided to undergo and give permission for PRK ____
LASIK ____ CustomVue LASIK _____
I declare that I understand the following information:
1. The goal of PRK, LASIK or CustomVue LASIK is to reduce or eliminate myopia, hyperopia, and/or
astigmatism or mixed astigmatism.
Page 1 of 4
CATARACT AND LASER CENTER, LLC
Consent for the use of the Excimer Laser for Performing
Photorefractive Keratectomy (PRK) / Laser In Situ Keratomileusis (LASIK)/ CustomVue LASIK (circle one)
2. RISKS: I understand that as with all forms of treatment, the results in my case cannot be guaranteed. There
is NO GUARANTEE that I will completely eliminate my reliance on eyeglasses and/or contact lenses. It is
possible that the treatment could result in undercorrection, where some degree of refractive error may
remain requiring the use of glasses and/or contact lenses. The treatment may also result in overcorrection,
causing refractive error, which may or may not require the use of glasses and/or contact lenses. It is possible
that dependence on reading glasses may be required at an earlier age. The treatment may also result in a
change of my astigmatism that could require the use of glasses and/or contact lenses. I understand further
treatment may be necessary, including a variety of eyedrops, the wearing of glasses and/or contact lenses
(hard or soft), or additional treatments including surgery.
A. Another risk is the occurrence of infection during the healing of the cornea. The incidence of infection is
greater during the first three days; however, healing may take as long as a week or more.
After PRK, patients have experienced haze. Haze presents itself in patients as though one were seeing
through a dirty window. Haze is not the initial blurriness experienced immediately after the treatment but
may become evident in weeks or months to follow. For LASIK, it has been reported through studies, that
there are also risks of developing haze. However, the rate of occurrence is very low compared to PRK.
B. Scarring may be persistent or infrequently recurring, requiring frequent surgeries and possibly producing
loss of visual sharpness of clarity.
C. Night glare is very common early on in the healing process. However, higher myopic patients are at a
greater risk of permanent glare.
D. Blurriness is very common in the healing process. It generally takes three to 10 days to clear. However
patients should recognize it may take longer. Full recovery especially from PRK, takes 4 to 6 months and a
percentage of patients may take up to 12 months. A small percentage of patients develop irregular corneas
that reduce sharpness, clarity, and crispness to their vision. Patients may not be able to read the last two or
more lines of the eye chart regardless of corrective lens assistance.
E. There is a percentage of risk of LASIK patients experiencing a corneal flap complication. A corneal flap
that is too thin may result in postponement of the procedure, prolonged visual recovery and/or temporary or
permanent blurred vision. Other potential corneal flap complications include a corneal flap incision, which
is too long, resulting in a free flap; this may increase the potential for prolonged visual recovery, blurred
vision, and epithelial ingrowth. Corneal flaps that are too short necessitate postponing the procedure. The
most potentially serious risk is a corneal flap that is too deep, which results in perforation of the eye, but this
is very rare.
F. During the first several hours after a LASIK procedure, the epithelial protective layer grows over the
corneal flap. There is potential of developing epithelial cell growth underneath the flap. This is more
common in people whose natural epithelial protective layer is not adequately attached to the eye surface.
G. There is a risk of inducing astigmatism greater than the pretreatment status or appearing in another part
of the cornea.
3. I understand that if I need reading glasses prior to treatment, I will likely need reading glasses after this
treatment. I also understand that if I do not currently need reading glasses, I may need them at sometime
after the surgery.
4. I understand that as with any form of surgery the outcome can never be guaranteed. The benefits of excimer
laser therapy also cannot be guaranteed.
5. (FEMALE ONLY) I am not pregnant or nursing. If it is possible that I am pregnant, then I will take a home
pregnancy test to ascertain that I am NOT pregnant, since pregnancy could adversely affect my treatment
results. If the results of the test are positive, I will NOT undergo treatment until the results are proven
Page 2 of 4
CATARACT AND LASER CENTER, LLC
Consent for the use of the Excimer Laser for Performing
Photorefractive Keratectomy (PRK) / Laser In Situ Keratomileusis (LASIK)/ CustomVue LASIK (circle one)
incorrect or I will reschedule the treatment after I am no longer pregnant or nursing. If I become pregnant in
the six (6) months following treatment, I will notify my eye doctor immediately.
6. I understand that as a result of the treatment there is a risk that my vision may be made worse.
7. I understand that treatment should not be performed on persons with uncontrolled vascular disease or
autoimmune disease, or on patients who are immunocompromised or on drugs or therapy which suppress
the immune system, so I will tell the doctor if I have any of these or other medical conditions.
8. I understand the treatment should not be performed on persons with signs of keratoconus since eyes with
this condition may have unstable corneas.
9. I understand that treatment should not be performed on persons known to have a previous history of keloid
formation (excessive scar formation) because their corneal healing response is less predictable.
10. I understand that partially and fully sighted eyes have been treated with the excimer laser in the past. The
long term effect associated with the PRK, LASIK or CustomVue LASIK procedures are not fully known.
11. I give permission for the medical data concerning my operation and any subsequent treatment to be
submitted for outcome data analysis. I understand that my identity will be kept strictly confidential in any
reports or journal articles.
12. I understand that this treatment is an elective procedure and that I do not have to have this treatment. I
understand that PRK, LASIK or CustomVue LASIK treatment is not reversible.
13. I understand that PRK, LASIK or CustomVue LASIK treatment requires follow-up care at frequent
intervals for one year after treatment and I agree to return for required examinations.
IMPORTANT INFORMATION







The three forms of Laser Vision Correction known as PRK, LASIK, and CustomVue LASIK are permanent
operations to the cornea; it cannot be reversed.
Alternatives to PRK, LASIK, and CustomVue LASIK include glasses, contact lenses, RK, Conductive
Keratoplasty and Intraocular Lenses.
PRK, LASIK, and CustomVue LASIK are NOT laser versions of radial keratotomy (RK); they are
completely different from one another.
Refractive error must be stable (within +/-0.5D) for at least one year before the surgery.
The following risks of Laser Vision Correction (PRK/LASIK/CustomVue LASIK) surgery should be noted:
 Transient complications: pain (24-48 hours), corneal swelling, double vision, feeling something in the
eye, shadow images, light sensitivity, tearing and pupil enlargement. These problems may last up to
several weeks.
 Adverse events: night vision difficulty (1%); elevation of intraocular pressure (2%); cloudy cornea
affecting vision (2%); overcorrection or become farsighted (5%); undercorrection or still nearsighted
(6%); loss of best vision that can be achieved with glasses (7%); mild halo (10%); and, minor glare
(10%).
If both eyes are treated on the same day, there may be some additional associated risks such as infection.
The following benefits of Laser Vision Correction surgery should be noted:
 Nearsightedness, Farsightedness, and/or Astigmatism may be reduced so that the amount of time during
the day contact lens or eyeglasses are used is reduced or eliminated.
 Laser Vision Correction may be an alternative to eyeglasses in some patients who are intolerant of
contact lenses.
 Another alternative to correct nearsightedness, farsightedness, and/or astigmatism or mixed astigmatism.
Page 3 of 4
CATARACT AND LASER CENTER, LLC
Consent for the use of the Excimer Laser for Performing
Photorefractive Keratectomy (PRK) / Laser In Situ Keratomileusis (LASIK)/ CustomVue LASIK (circle one)

Patients considering Laser Vision Corrective surgery should:
 Discuss fully with one or more eye doctors the complications of surgery, the risks and the time required
for healing, and have a complete eye examination before making a final decision.
 Please read this Patient Informed Consent Document carefully before signing.
STATEMENT OF VOLUNTARY PARTICIPATION
In signing this Informed Consent Form for Photorefractive Keratectomy (PRK), Laser in situ
Keratomileusis (LASIK), or CustomVue LASIK I am stating that I have read this Informed Consent (or
it has been read to me) and I fully understand it and the possible risks, complications and the benefits
that can result from the treatment.
Although it is impossible for the doctor to inform me of every conceivable complication that may occur, the
doctor has answered all of my questions to my satisfaction. I understand that if I have any questions with
respect to the treatment, I can call my physician.
By signing this form, I acknowledge that I understand the following:
1. The Photorefractive Keratectomy (PRK) treatment has been explained to me in terms that I understand;
2. The Laser in situ Keratomileusis (LASIK) treatment has been explained to me in terms that I understand;
3. The CustomVue Laser in situ Keratomileusis (LASIK) treatment has been explained to me in terms that I
understand;
4. I have had the opportunity to have my questions answered; and
5. I fully understand the possible risks, complications and benefits that can result from treatment.
MY DECISION TO UNDERGO THE PHOTOREFRACTIVE KERATECTOMY (PRK), LASER IN
SITU KERATOMILEUSIS (LASIK) or CustomVue LASER IN SITU KERATOMILEUSIS (LASIK)
FOR NEARSIGHTEDNESS, FARSIGHTEDNESS, WITH OR WITHOUT ASTIGMATISM
TREATMENT HAS BEEN MY OWN AND HAS BEEN MADE WITHOUT DURESS OF ANY KIND.
Eye to be treated:
Right Eye (OD)
Left Eye (OS)
Both (OU)
____________________________________________
Patient's Name (Type or Print)
___________________________________________
Patient's Signature
________________________
Date
___________________________________________
Physician's Signature
________________________
Date
___________________________________________
Witness' Signature
________________________
Date
Page 4 of 4