Board-Certified Ophthalmologist

Phone 503.581.5287  
Fax  503.386.1377  
Enhancement Waiver

I, , have been informed that the FDA
Patient Name

has not yet completed the trial study phase of CustomVue treatments for LASIK enhancements. However, Dr. Dodd

is not aware of any increased risks with CustomVue LASIK enhancements compared to FDA-approved

Conventional LASIK enhancements.

I understand the above stated information and that CustomVue LASIK enhancements are considered an off-label

use of the VISX Star S4-IR excimer laser. I choose to proceed with the CustomVue LASIK enhancement procedure.
Patient Signature
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301