Request for Dr. Janot & Dr. Bulathsinhala to provide post op care: I hereby request that Dr. Robert Janot or Dr. Nilupul Bulathsinhala, provide my post operative care following cataract surgery (or surgeries). I understand that there may be additional fees associated with his care, over and above what my insurance covers, as outlined below.


I can still see my cataract surgeon, if desired: I understand that I may see my cataract surgeon at any time during the postoperative period, instead of, or despite of, the above request. I also understand that I may contact my cataract surgeon’s office at any time after my surgery.


Insurance & additional fees: I understand that my cataract surgeon and Dr. Janot or Bulathsinhala will submit separate claims to my insurance company for their services. Additionally, some services are not covered by insurance and I understand that I will be responsible for these non covered services.

I agree to pay, at the time services are rendered by Dr. Janot, Dr. Bulathsinhala, and/or their staff:
•Any co-payment owed (varies by insurance company)
•Refraction to determine best vision (typically done at final post operative visit): $40
•Optomap Retinal Imaging (typically done at final post operative visit): $55
•Temporary Contact Lens & Fitting (if needed to provide balanced vision between surgeries; Dr. Janot’s staff will handle all insertion / removal / cleaning / replacements, as necessary): $105


Premium Services / Lenses: I understand that I may also have the option to choose LASER assisted cataract surgery &/or premium intraocular lenses (such as astigmatism or multifocal). These are NEVER covered by insurance and I understand that I will have to pay extra for these (fees vary by surgeon and will be quoted & collected by the surgeon’s office).

Over and above the additional cost for LASER assisted surgery &/or Premium IOLs paid to my cataract surgeon, I understand that there are additional and separate fees to be paid to Dr. Janot & Dr. Bulathsinhala, to manage my case, which I will pay for at my first post operative visit:

Vision Source’s additional fee to manage LASER Assisted Cataract Surgery: $300 per eye

Vision Source’s additional fee to manage Premium Intraocular Lenses: $300 per eye
I understand that Dr. Janot & Dr. Bulathsinhala will remain in communication with my cataract surgeon by phone, text, and / or electronic transmission of my examinations during the postoperative period. I have read and understand this form and that it is my wish to have Dr. Janot or Dr. Bulathsinhala provide my eyecare following cataract surgery.