LASIK Counseling Checklist
Patient Name:______Date of Consultation:______
____ Explain how LASIK corrects vision.
• Use book analogy and patient's pachymetry values.
• Discuss custom LASIK and benefits of this technology.
____ Discuss typical healing and possibility of under- or over-response to laser.
____ Discuss possibility of needing an enhancement; approximately one in 10 patients may decide to have an enhancement.
____ Discuss patient's degree of prescription and chances of reaching 20/40 or better unaided visual acuity.
____ Remind patient that LASIK is NOT a guarantee that he/she will never have to wear glasses again.
____ Discuss presbyopia and need for eyewear after age 40.
____ Discuss possible need for temporary distance, night driving or other corrective eyewear. Educate patient the correction is temporary until an enhancement may be performed and is not covered in the cost of the LASIK procedure. Also, inform patient as he/she ages, the need for correction may also arise (i.e. reading glasses).
____ Discuss initial side effects, including starbursting, glare, fluctuating vision and dryness and possible complications, such as ingrowths, corneal flap complication, DLK, flap wrinkles and infection.
____ Discuss required medications.
____ Inform patient of day-of-surgery expectations.
____ Inform patient of expectations and limitations after surgery.
____ Advised not to proceed with surgery if pregnant or nursing. You should avoid pregnancy for the first 3 months following surgery in the event that you need an enhancement and additional surgery and medications need to be used.
____ Inform patient of day of surgery expectations.
____ Inform patient of expectations and limitations after surgery.
____ Make patient aware of the need for a driver for the day of surgery and for the one-day post-operative exam until legal driving vision is verified.
____ Patient understands when contact lenses must be discontinued:
• One week for spherical lenses.
• Two weeks for extended and toric lenses.
____ Give a price quote and have the patient sign fee agreement.
____ Give Restasis Rx for use 2 weeks prior to surgery (2x day) for patients with dry eye.
____ Surgery appointments scheduled up to one month, given to patient and copy put in chart.
The above points of education have been discussed with me and I understand what has been discussed. I have also had the chance to have all my questions answered.
______
Patient SignatureDate of Exam
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LASIK counselorDate of Exam