Agreement for Dr. Janot to Provide Post-Op Care Agreement for Dr. Janot to Provide Post-Op Care I hereby request that Dr. Robert Janot, a Board Certified Optometric Physician, perform all portions of my post operative care following cataract surgery (or surgeries). I request this due to his familiarity with my history and my case, as well as the fact that it will help me avoid the inconvenience of, otherwise, traveling to the surgeon’s office for after care. I understand that I may see my cataract surgeon at anytime during the postoperative period, despite the above request, although it may involve travel, as well as other scheduling issues. I also understand that I may contact my cataract surgeon’s office at any time after my surgery. I understand that my cataract surgeon and Dr. Janot will submit separate claims to my insurance company for their services, but, that I will pay the exact same as if all of my care were provided by my cataract surgeon. I understand that I have the option to choose premium services / intraocular lens (IOL) materials over and above what my insurance covers. These are never covered by insurance and I will have to pay for these myself. These premium services / IOL fees will be quoted by my cataract surgeon and are not listed here. If you opt to have any of the following, Dr. Janot may assess additional and separate fees to manage your case, which you will be responsible for at your first post operative visit: Dr. Janot’s additional fee to manage LASER Assisted Cataract Surgery: $250 per eye Dr. Janot’s additional fee to manage Premium Intraocular Lenses: $250 per eye I understand that Dr. Janot will remain in communication with my cataract surgeon by phone, text, and / or electronic transmission of my examinations during my postoperative care period. I understand that he will notify my cataract surgery immediately, in the event of any complications I may experience. Again, I understand that I may also contact my cataract surgeon at any time after my surgery. Name of Patient* First Last Signature or Mark of Patient / Caregiver*If the patient is unable to sign, his/her mark is also acceptable, so long as it is co-signed by the caregiver. If the patient is unable to even mark the box, a caregiver may sign in place of the patient.Date* MM slash DD slash YYYY Caregiver's NameThis field only needs to be completed if the caregiver is signing or co-signing this form. First Last NameThis field is for validation purposes and should be left unchanged.