Board-Certified Ophthalmologist

Phone 503.581.5287  
Fax  503.386.1377  
Autoimmune Surgery Waiver

I, , understand that, due to my autoimmune disorder,
Patient Name
there is an increased risk in performing the iLASIK surgery. However, the FDA has completed testing which

conclusively finds that iLASIK can be performed effectively and safely in selected patients with stable and

controlled systemic diseases.
I understand the above statement and willingly proceed with iLASIK.

Patient Signature
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301