Warfighter Refractive Eye Clinic Womack Army Medical Center Fort Bragg, NC 28310

Transcription

1 Warfighter Refractive Eye Clinic Womack Army Medical Center Fort Bragg, NC Complete packet provided by the Refractive Eye Clinic, WAMC, 2 South (2S). Commander s Endorsement Required (example enclosed in packet). No contact lens wear for 14 days ("soft" lenses) and 30 days (rigid gas permeable "hard" lenses) prior to preoperative exam and surgery appointment. Recent eye exam required (within 12 months from preoperative appointment). Prior refractive surgery patients will need to have previous surgical information available when submitting packet (pre-surgery glasses prescription, treatment plan, type of surgery). Also required, an eye exam greater than 12 months from preoperative exam to show prescription stability. Make a copy of the packet for your personal records. Turn-in completed packet to the Refractive Surgery Clinic located 2 South (2S), second floor, nearest to the Reilly Road Entrance.

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3 Warfighter Refractive Eye Surgery Program Womack Army Medical Center Fort Bragg, NC MCXC-DOS-REC Criteria for Selecting Soldiers for Laser Eye Correction under the Warfighter Refractive Eye Surgery Program (WRESP) 1. At least 18 months remaining on active duty at the time of surgery, or in conjunction with a reenlistment action which is executed. 2. Assigned to a unit whose mission involves operations at the time of battle or behind hostile lines. Special operations and combat arms units such as Infantry, Field Artillery and Armor Battalions should be given first priority. 3. Combat Service Support unit personnel in present assignments in a division of separate brigade should be the second priority. 4. Other active duty service members as space is available. 5. Non-active duty personnel are not authorized treatment under this program. 6. Personnel selected should have at least 12 months remaining in the same or similar unit and should have no adverse personnel actions pending. 7. Individuals selected will be removed from the waiting list should their circumstances change such that they would be in contravention of the above guidelines. Unit commanders are responsible to monitor their selected soldiers. 8. Treated individuals must return for follow-up visits as specified postoperatively in the applicable protocol as a condition of treatment. 9. Patients that have been pregnant or nursing must wait six months before having refractive surgery. 10. Patients that are currently pregnant, nursing, or planning to become pregnant must wait until six months after giving birth and ending nursing before having refractive surgery. APR 2016

4 DEPARTMENT OF THE ARMY YOUR UNITS LETTERHEAD (OFFICE SYMBOL) (DATE) MEMORANDUM FOR Commander Womack Army Medical Center, ATTN: Warfighter Refractive Eye Surgery Clinic (WRESP), Fort Bragg, NC SUBJECT Commander s Endorsement of Refractive Eye Surgery 1. (NAME, RANK, SSN, MOS) is provided my endorsement/permission to be evaluated and considered for enrollment in the Refractive Eye Surgery Program. The above Soldier as of date of this endorsement has at least 12 months retainability at current duty station and at least 18 months retainability from the date of surgery in the Army. a) The scheduled ETS/retirement date is (DATE). b) Orders for DEPLOYMENT date is (DATE). 2. I realize after the surgery, the Soldier will have the following profile for typically 30 days and up to 90 days: a) No Airborne operations. b) No swimming c) No night operations d) Must keep all follow-up appointments to include (but not limited to): 1 day, 7 days, 1 month, 2 months, 3 months, 6 months, and 12 months. 3. I further realize that the soldier cannot be deployed for 30 days and up to 90 days after surgery. 4. I have read both the Chief of Staff of the Army s memorandum as well as the Surgeon General s memorandum to include the eight eligibility criteria and ensure the above Soldier meets the criteria and will comply with the follow-up requirements. 5. Point of contact for this memo is the undersigned (or his/her representative) at (PHONE NUMBER) Soldier Information: Duty MOS: Cell Phone: Home Address: 1 st Line Supervisor s Phone: COMMANDER'S SIGNATURE BLOCK MUST BE ORIGINAL SIGNATURE BLACK INK ONLY (NO COPIES) Update APR 2016

5 WARFIGHTER REFRACTIVE EYE SURGERY PROGRAM Phone Number: (910) or (910) Patient Name: Rank: MOS: SSN: D.O.B: Phone (Work) (Home) (Cell) Are You Deploying? Yes No When? Have You Deployed With Overseas Contingency Operations? Yes No When? STATUS: AD, NG, or USAR COMDOR: USA USAF USN USMC ETS / Retirement Date: Are you on orders to PCS? Yes No Current Unit: (No Abbreviations) Have you worn contact lenses in the past? Yes No When? Are you currently wearing contact lens? Yes No * NOTE: SOFT CONTACT LENSES MUST BE OUT FOR TWO WEEKS AND RIGID/TORIC CONTACTS MUST BE OUT FOR ONE MONTH BEFORE THE PREOPERATIVE EXAMINATION. Have you ever been told that you have Kerataconus? Yes No Have you ever had a refractive eye surgery procedure? Yes Pre-Surgery Packet and see ENHANCEMENT REQUIREMENTS below). Have you been vaccinated for Smallpox? Yes No When? Are you pregnant or nursing? Yes No No (If so, please attach a copy of those records with your * Refractive Eye Surgery is an option for vision correction 6 months after pregnancy/breast feeding. This helps ensure good vision and protect the health of the baby. Have you been pregnant or nursing within the past 6 months? Yes No Has your prescription changed more than 0.50 diopters within the past year? Yes No PATIENTS SHOULD FIT ONE OF THE FOLLOWING REFRACTIONS: Myopia: -1.0 to Myopia with Astigmatism: 0 to diopters / myopia with MINUS 0.75 to 4.00D astigmatism Hyperopia (symptomatic): +1.0 to diopters with no more than 4.0 diopters of astigmatism (maximum spherical equivalent refractive error <+3.50 diopters) Visual acuity must be 20/40 or worse ENHANCEMENT REQUIREMENTS: Must meet all criteria above It is the responsibility of the Soldier to provide all documents of previous refractive surgery, to include preoperative and postoperative exams. Follow-up examinations must show that there have been no changes greater than 0.50 diopters within one year. If the WRESP Clinic refractive data, you must have one year of exams to collect data and rule out changes greater than 0.50 diopters before any surgery is planned. ADDITIONAL CRITERIA: You must have written permission from your commander in order to receive refractive surgery (commanders endorsement must be dated within 90 days of surgery date). You will be non-deployable for up to 90 days after surgery. You will have a profile that prohibits you from participating/conducting the following: field duty, camouflage face paint, wearing a gas mask, parachuting, or night operations for 30 days after surgery. No driving military vehicles for 14 days after surgery. Special operations Soldiers may receive PRK, LASEK and LASIK with a waiver per direction of the USASOC Surgeon. You will have mandatory follow-up visits at 1 day, 7 days, 1 month, 2 months, 3months, 6 months and 12 months following surgery. (THIS IS WHY 12 MONTHS LEFT IN PRESENT DUTY ASSIGNMENT IS REQUIRED). If you recently had the smallpox vacinnation, you will need to wait 3 weeks before having refractive surgery. After having refractive eye surgery, you must wait until you are no longer using steroid drops before receiving smallpox vaccination (depending on the type of surgery a normal regimen of steroid drops is two weeks to four months after surgery). JUN 2017

6 DEPARTMENT OF THE ARMY WARFIGHTER REFRACTIVE EYE SURGERY PROGRAM WOMACK ARMY MEDICAL CENTER FORT BRAGG, NORTH CAROLINA MEMORANDUM FOR RECORD SUBJECT: Patient Briefing Conformation I,, and have been briefed on the policies and NAME SSN MOS procedures for the Warfighter Refractive Eye Surgery Program at Womack Army Medical Center. I understand that wearing contact lenses interferes with the preparation and performance of refractive eye surgery. I am aware that soft contact lenses must be removed for 2 WEEKS prior to any preoperative or surgery appointments. Rigid Gas Permeable (hard) contact lenses must be removed for 1 MONTH prior to any preoperative or surgery appointment. I have been informed that I must remove my contact lenses, if applicable, prior to requesting a preoperative appointment for me, therefore, as of, I have removed my contact lenses and agree not to wear them again. DATE TAKEN OUT Contact lenses cause the eye to swell. Wearing contacts impairs the doctor s impression of the eye during the preoperative appointment and surgery if the contact lenses have not been removed for the sufficient amount of time. I understand if I attend the preoperative appointment, and it is determined that my contact lenses have not been removed for the sufficient time, my appointment will be canceled. I further understand, I will be moved to the bottom of the waiting list, and I may not be rescheduled for a period of up to two months. I understand that I am required to have a driver on the date of my surgery and all postoperative/ follow up appointments until the doctor has cleared me to drive. If I choose to call my driver after my surgery is completed, I understand I will not be permitted to leave the clinic until my driver arrives to retrieve me. In the event of a schedule conflict, or if I cannot attend my appointment, it is my responsibility to notify the Refractive Eye Clinic prior to the appointment time. Tardiness of more than fifteen minutes will be considered a missed appointment. Patients who fail to cancel preoperative or surgery appointments may not be rescheduled. I understand that it is my responsibility to keep all follow-up appointments scheduled with the WRESP Clinic. I am aware that the follow-up period after refractive eye surgery is one year and that I am expected to be evaluated at least: 1 day, 7 days, 30 days, 60 days, and 90 days following surgery. I am also expected to be seen at 6 and 12 months postoperatively, accommodating TDY and leave periods. My signature acknowledges that I will comply with all rules set forth by the WRESP Clinic. Failure to comply may result in my being deemed ineligible for refractive eye surgery and possible punishment under the Uniformed Code of Military Justice (UCMJ). Point of contact for this memorandum is at NAME PHONE NUMBER Patient Signature Date:

7 DEPARTMENT OF THE ARMY WOMACK ARMY MEDICAL CENTER FORT BRAGG, NORTH CAROLINA MCXC-DOS-REC SUBJECT: Eligibility for Refractive Surgery 1. I am eligible for Refractive Surgery and specifically (initial as correct or use N/A, if not applicable): A. I am NOT member of the National Guards or Reserves B. If I AM a member of the National Guards or Reserves, and I certify that I am either: 1. In status as AGR or, 2. Have provided a copy of my orders indicating I will continue in an active duty status for at least 18 months after the date of surgery C. I will remain on active duty for at least 18 months after the date of surgery with no intention of deactivation, ETS, discharge, etc. (ETS DATE) D. My command is aware of the fact that I may not be eligible to deploy for at least 1-4 months after my surgery based on healing. E. If I am coming from off post, I have arranged for my home station Ophthalmologist (NOT OPTOMETRIST), to supervise postoperative care. 2. The above statements have been verified as accurate and true by my initials above and my signature below. (Printed name + last 4) (Signature) (Date)