Contact Lens Evaluation for Contact Lens Wearers
As a contact lens patient to our practice, it is necessary for the doctor to perform
additional testing to assess the fit of your present contact lenses. Contact lenses are
FDA-approved medical devices and must be checked yearly by the doctor.
Prescriptions and contact lenses cannot be dispensed by your doctor if your
prescription and fit assessment is older than one year. This part of the exam is not
routinely covered by most insurance. If you need further clarification, the doctor will
discuss the professional contact lens service fee to be charged prior to the service
being rendered.
The professional service fee for this additional part of the exam is $39.00. If your
present lenses that have been fit and prescribed elsewhere, are determined to now
have a less than acceptable fit or are not safe for the health of your cornea, a contact
lens re-fit will be advised.
The professional service fee for any recommended re-fit may vary according to the
extent of changes needed and the number of follow up visits required to ensure a
successful and healthy contact lens fit going forward. For both new and existing
patients, re-fitting fees would apply if you change to multi-focal contact lenses or
toric contact lenses, and/or the discontinuation of your existing contacts necessitates
changing to a new lens style or brand.
The contact lens evaluation $39 fee is a yearly fee for all patients to Eye Physicians
and Surgeons.
Payment for the contact lens evaluation service fee is expected at the time of the
examination and is non-refundable.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS
___YES, I would like a contact lens evaluation today in order to update my contact
lens prescription and have the ability to purchase contacts for the next 12 months. I
understand that the evaluation fee must be paid at the time of service.
___NO, I do not want a contact lens evaluation today and understand that I will not
be able to purchase contacts without an updated lens prescription.
______________________________ ____ /______ /______
Patient / Parent or Guardian Date
