Contact Lens Form

Contact lens prescription will not be given until a proper fit has been established and all professional services are paid in full. If you are not able to make all of your follow-up appointment you will not receive a contact lens prescription.

Patient must return for his/her follow-up no later than sixty (60) days form the date of the initial contact lens fitting examination. A late follow-up fee of $35.00 will be charged after sixty (60) days from the initial contact lens fitting examination.

CERTIFICATION

I hereby certify that all the information I have provided is true and correct and that I will abide by the contact lens care and handling instruction discussed with me by the office
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I have read and understand the office policies as stated above
I have read and understand the office Privacy Notice
I gave permission for this office to file claims with my insurance company