Corporate Office | 653 Camino de los Mares #103 | San Clemente, Ca 92673

Mission Viejo Office | 26726 Crown Valley Pkwy #220 | Mission Viejo, CA 92691 Laguna Hills Office | 23521 Paseo de Valencia #306 | Laguna Hills, CA 92653

Additional Locations | Irvine | Costa Mesa | Big Bear | Lake Arrowhead Phone: (949) 489-2218 | Fax: (949) 496-3604 | www.tayanieye.com

Dear Patient: Welcome to the Tayani Eye Institute. Thank you for considering us for your eye care. We have prepared this packet to educate you about the following items:

• What is Cataract? • Cataract Surgery • Lens implant options that will replace the cataractous lens in your eye

Please review and complete the following forms before your appointment:

• New Patient Registration Packet o Health History o Insurance Plan Benefits o Tayani Eye Institutes policies regarding confidentiality and payments.

• Vision Lifestyle Questionnaire- this will allow us to make recommendations regarding what options best suit your visual and lifestyle needs.

Bring these forms with you on the day of your appointment. DO NOT mail these forms.

On the day of your appointment, be prepared to provide the following:

• Insurance Card • Valid Picture Identification Card (Driver’s License, ID Card, etc) • If you have insurance, you will be responsible for your co-pay.

o If you were referred by your primary care physician and your insurance carrier requires a referral, please contact our office prior to your appointment to ensure that we have received one.

• If you are a cash patient, you will be responsible for a payment for the initial cataract consultation which includes all necessary tests.

o We gladly accept Visa, Mastercard, American Express, Discover, Personal Checks and Cash.

Your appointment is on ____________________ at __________________

in the _________________________________ office.

Should you have any questions, please feel free to call us at (949) 489-2218. We look forward to seeing you and appreciate you scheduling with The Tayani Eye Institute. Sincerely, Medical Staff THE TAYANI EYE INSTITUTE

Vision Lifestyle Questionnaire                         Name: ____________________________________ Date: _______________________________ 

Vision Lifestyle Questionnaire/ Tayani Eye Institute/ 12.8.10 AC

The term “cataract” refers to a cloudy lens within the eye. When a cataract is removed, a lens implant is used to replace the cloudy human lens. If it is determined that a lens implant is appropriate for you, your answers will help us select an implant that best suits the vision demands of your lifestyle. (2 page questionnaire front and back)

1. Does wearing glasses bother or frustrate you? Yes No

2. If lens replacement is recommended for you; please rate your vision preferences at the following distances?

Distance Vision: driving, golf, tennis, other sports, watching TV. Prefer no distance vision glasses I wouldn’t mind wearing distance glasses

Mid-range Vision: computer, menus, price tags, cooking, board games, items on a shelf. Prefer no mid-range vision glasses I wouldn’t mind wearing mid-range glasses

Near Vision: reading books, newspapers, magazines, doing detailed handwork. Prefer no near vision glasses I wouldn’t mind wearing near glasses

3. Please check the single statement that best describes you in terms of night vision: Night vision is extremely important to me, and I require the best possible quality. I want to be able to drive comfortably at night, but I would tolerate some slight imperfections. Night vision is not important to me.

4. If you had to wear glasses after surgery for one activity, which activity would you be most willing to use them for?

Distance Vision Mid-range Vision Near Vision

5. How many pairs of (reading and/or distance) glasses do you currently own? ___________

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