Contact Lens Policy Agreement

Contact Lens Policy Agreement

I understand that a comprehensive eye examination is something completely independent of contact lens services. There will be a separate charge for each contact lens service provided. A contact lens service is defined as a contact lens fitting and/or contact lens evaluation.

I understand that I am responsible to pay for my contact lenses and/or contact lens services in full at the time of pick-up whether or not I have insurance coverage* (Special Rules Apply for NVA and VSP insurance). If contact lenses are not ordered through our office, I understand that the contact lens service fees will be due at the time that service is provided.

I understand that I will be responsible for all contact lens services—contact lens evaluations and/or contact lens fittings. I understand that this applies to both a first time wearer of contacts or an established contact lens wearer.

I understand that to keep my contact lens prescription current, I will be expected to have an eye exam and contact lens fitting and/or evaluation each year. Therefore, I understand that my contact lens prescription expires in one year.

I understand the advantages of a back up pair of eyeglasses in the event I suffer a lost or torn contact lens, eye infection, eye injury, or run out of contacts after my annual eye exam and contact lens service was due.

I am aware of the risks, advantages, and disadvantages of contact lens wear.

I understand it will be my responsibility to request and submit an itemized bill to my insurance company for reimbursement.

I understand that there will be only a 50% refund on any returned materials (unopened boxes only). These materials must be returned within 60 days of my initial contact lens service visit.

I understand that there will be no refund on any contact lens service fees.

By digitally signing your name below, you agree with the terms of this agreement.

  • Please type the full name of the patient or patient's representative.
  • Date Format: MM slash DD slash YYYY