specialty_contact_lens_agreement2.docx | |
File Size: | 35 kb |
File Type: | docx |
SPECIALTY CONTACT LENS CONSENT FORM
Please read this contact lens exam policy, sign and date the bottom. By signing, you agree to honor these terms and agree to pay for any contact lens related fees in full.
CONTACT LENS FITTING:
Kerataconnic and other specialty contact lens designs are custom fittings. The fitting fee is $600.00. This includes the initial fitting process, follow up visits for up to three months as well as insertion and removal training time. This fitting fee is due at the initial fitting appointment and is nonrefundable.
CUSTOM CONTACT LENSES:
The cost of Custom Contact Lenses range from $550.00-$700.00 per lens depending on their design. All custom contact lens orders require a deposit of 50% at the time lenses are ordered. When the initial lenses are dispensed the remaining balance is due. There are no additional charges when even exchanges (initial lenses returned, new lenses dispensed) due to Rx or fit adjustments are done during the warranty period of 45 days. In the rare event that specialty contact lenses are not tolerated, a refund in the form of store credit will be issued minus 20% within the warranty period.
CONTACT LENS ANNUAL EXAM:
A contact lens Rx is valid for one year. An annual exam at a fee of $225.00 is required to maintain your contact lens Rx. At that visit the contact lens fit, the Rx and ocular health are assessed.
INSURANCE:
Most specialty contact lenses are medically necessary for ocular health and best visual acuity option. Therefore, medical &/or vision insurance may cover part of the contact lens fitting and contact lens costs. It is the patient’s responsibility to research their benefit and file to be directly reimbursed. Dr. Cutler will gladly supply any of the paperwork required.
I am happy to clarify this process further if you have any questions or concerns.
Patient Name:
Parent (if under 18):
Date: