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Home » Contact Us » Contact Lens Acknowledgement

Contact Lens Acknowledgement

  • I understand that I have been given initial diagnostic contact lenses for evaluation purposes only. These lenses DO NOT represent a finalized contact lens prescription.

    In order for this office to finalize the contact lens prescription and release it to you, you MUST RETURN (wearing your diagnostic “trial” contact lenses in your eyes) for a contact lens follow up appointment within 30 days of receipt of your lenses. If for any reason you are unable to return for your follow up appointment within 30 days as instructed above, the FDA requires that a new pair of diagnostic contact lenses be issued to continue the fitting process. Diagnostic “trial” lenses are available for the fitting process only. Once the final prescription is written, if new trial lenses are requested, that may incur an additional administrative fee.

    It is your responsibility to schedule and return for follow up care.

    Your fee today of $170 (sphere) or $195 (toric, monovision, multifocal, gas perm), or$370 (specialty gas perm, soft toric multifocal or Synergeyes) includes your Annual eye health examination, Vision assessment with spectacle Rx, and Contact Lens evaluation, fitting, diagnostic lenses, and any additional training. This fee also includes 90 days of follow-up care. Fees for routine visits for issues related or unrelated to contact lens use after the above 90-day follow-up term will result in a $40 fee. Fees for medical issues related or unrelated to contact lens use will incur additional fees based on the level of severity of the issue.

    All fees are expected at the time of service. A receipt with a diagnosis will be provided for your submission to your insurance carrier for reimbursement.

    Returning for follow-up care within 60 days of your anniversary date will insteadprompt your Annual eye health examination, vision assessment with new spectacle Rx,and contact lens evaluation.

    I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS FORM IN ITS ENTIRETY.

  • Date Format: MM slash DD slash YYYY

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