Eye Exam & Dilation Online Form

CONTACT LENS AGREEMENT

The contact lens evaluation is an additional $55-85 fee to the yearly comprehensive eye exam, which includes a glasses prescription. The evaluation includes all necessary follow ups, trial contact lenses and sample solution within the first 60 days. After the first 60 days, there will be a $30 fee for each additional visit. Contact lens evaluation fees are non-refundable.

The evaluation consists of determining the proper lens type and fit based on the curvature of your eyes, determination of correct contact lens prescription, as well as checking the clarity of vision and fit of the lens. Like glasses prescriptions, contact lens prescriptions need to be updated yearly. Many times, your contact lens prescription will be different than your glasses prescription. Additionally, and most importantly, you will be assessed for any health issues associated with contact lens wear.

HIPAA PRIVACY POLICY PATIENT CONSENT FORM

I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

1. Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
2. Obtaining payment from third party payers (i.e. my insurance company)
3. The day to day healthcare operation of your practice