Contact Lens Agreement Digital Contact Lens Agreement Below you will find our policies for contact evaluations and lenses. If the information provided does not answer all of your questions, please ask any of our front desk staff.In order to have a contact lens evaluation you must have had a comprehensive eye exam within the last six (6) months. If your examination was not completed at EyeSymmetry Vision Center, you must have a copy of the examination results with you at the time of your visit. The contact lens evaluation is separate from the comprehensive eye examination. At your contact lens evaluation, our doctor will determine what size and type of contacts are right for you. Since most insurance companies deem contact lenses as a form of cosmetic vision correction, the fitting and the lenses are usually not covered. Contact lens prescriptions are distributed after the initial eye exam is completed, unless a patient is prescribed custom contact lenses. All evaluation fees must be paid in full at the time of your initial visit. If you choose to purchase contact lenses, a minimum of fifty percent (50%) must be paid as a deposit at the time of the order. Please note that the cost of the contact lenses is not included in the cost of the evaluation fee. PATIENT COMPLIANCE:Contact lenses are worn on the cornea and therefore considered a medical device. EyeSymmetry Vision Center has designed the evaluation procedures, wearing schedules, and follow-up examinations to ensure that your eyes remain healthy while wearing your new contact lenses. If you are non-compliant with the wearing schedule, or if you do not return for your follow-up examination(s) in a timely manner, we have the right to discontinue the contact lens evaluation. *The Evaluation fee is non-refundable and includes all contact lens follow-up visits within ninety (90) days of your initial evaluation. Any visits for contact lens follow-up after ninety (90) days will be done at an additional charge. Initials:(Required)*Specialty contact lenses must be picked up within sixty (60) days of notification of their arrival, or they will be returned to the manufacturer and fifty percent (50%) restocking fee will be charged. Initials:(Required)RETURN POLICY:*Regular Disposable Lenses- Disposable contacts cannot be returned unless they are found to be defective. If you feel that you have received a lens or lenses that are in some way defective, please do not dispose of them; they may need to be returned to the manufacturer for analysis. We are not able to refund defective lenses, however, we will replace any boxes that are deemed defective by the manufacturer upon return. Initials:(Required)*Custom Designed/Specialty Lenses- For all custom designed/ specialty contact lenses, there is a restocking fee that ranges from fifty dollars ($50) to one hundred dollars ($100) an eye depending on the make and design of the lens. The lenses must be undamaged and be returned in the original case or vial that it was delivered in. If you feel that you have received a lens or lenses that are in some way defective, please do not dispose of them; they may have to be returned to the manufacturer upon return. Initials:(Required)Again, if there are questions about these policies, ask the front staff for clarification. Print Patient Name:(Required) First Last Signature of Patient/ Parent or guardian:(Required)Date(Required) MM slash DD slash YYYY Δ
