Advanced Technology Lens Disclosure and Consent Form

ADVANCED TECHNOLOGY INTRAOCULAR LENS DISCLOSURE AND CONSENT FORM

The purpose of this notice is to help you make an informed choice about whether you want to receive these items or services. Insurance does not cover Advanced Technology Intraocular Lenses. You are financially responsible for any copayments, coinsurance, and deductibles as well as any non-covered items and services

After determining if you are a good candidate for an advanced technology intraocular lens (IOL), your doctor may recommend one to you, but ultimately the decision to opt for an advanced technology IOL is yours. Based on the information provided on the cataract consent form and given the different IOL options available to you the decision is yours to make; it is optional. The major difference between cataract surgery with a traditional IOL versus cataract surgery with an advanced technology IOL is the degree of dependence on eyeglasses thereafter. Implantation of advanced technology IOL does not guarantee that you will be 100% free from glasses.

Surgery Date*

Date

Lens Selection*

Standard Monovision IOLAstigmatism Vision PlanEnhanced Vision PlanMaximum Vision Plan

Which Eye?*

Right EyeLeft Eye

The undersigned accepts full financial responsibility for the services described and selected above.

Patient Signature or person authorized to sign for patient*

Printed Patient Name*

Date*

Date

Patient Signature (or person authorized to sign for patient)Printed Patient Name

Best Phone Number*

Payment for Advanced Technology Lenses will be collected ~ 1 week prior to surgery.

Notes:

0/50

5901 Westown Parkway, Suite 200, West Des Moines, IA 50266