MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
Medical Center Eye Clinic
655 Medical Center Drive
Salem, OR 97301
(503) 581-5287
Co-Management Release Form
Patient Name:

I will be given an information sheet explaining the post-operative surgery instructions, appointments needed, and the care of my eye following surgery. This has been explained by my surgeon. l understand that l am to return to either my surgeon or regular ophthalmologist / optometrist following surgery for an appropriate period of time in order to ensure that my recovery is progressing normally.

Please choose one option below:

I have informed my surgeon that it will be more convenient for me to have my post-operative care preformed by my ophthalmologist/ optometrist when it is medically appropriate. l have discussed this program with my ophthalmologist / optometrist and he/she is willing to perform these services and consult with my surgeon as needed for my care. My ophthalmologist / optometrist also has agreed to provide my surgeon with a copy of my record after each post-operative visit.

My surgeon has assured me that l can contact his office at any time with any questions or for any problems, and if I choose to return to him at any time during the post-operative period, l may do so.

l have informed my surgeon that it will be more convenient for me to receive my post-operative care from him. It is my choice not to return to my ophthalmologist / optometrist for my post-operative care.



My Ophthalmologist / Optometrist:
My Surgeon:
Patient Signature:
Witness Signature:
Date and Time:
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com