Download File - 20/20 Eye Care

20/20 EYE CARE
10945 State Bridge Rd
Suite 306
Alpharetta, GA. 30022
Office: (678) 339-0423
A Family Eyecare Practice
Samia Idris, O.D.
Contact Lens History
Do you wear contact lenses?
Yes
No
Date of last contact lens exam: ___________________
Please circle the type of contact lenses you have:
Soft
RGP (Hard)
Which brand are they? _________________________________
Do you sleep in your contacts? ___________________________
Solution used to disinfect contact lenses: ____________________
Contact Lenses Policy
The Georgia State Board of Optometry requires that Contact Lens prescriptions expire one (1)
year from the date the lens specifications were determined. Any contact lens wearer therefore
has to go through a fitting procedure to complete the prescription even if the contact lens brand
still fits well and provides good ocular health.
Please be advised that the contact lens fitting is not part of the comprehensive eye exam.
(Please initial the lines below.)
_____ Most insurance plans cover the contact lens fitting exam if benefits are used towards the
purchase of contact lenses. If not please be advised that you will be responsible for this fee.
_____ When a trial set of contact lenses is given to you by the Doctor, you must return to our office
within 2 weeks to complete the fitting procedure to avoid ocular infection. If the fitting is not
completed contact lenses cannot be purchased and the prescription cannot be released. The trial
contact lenses need to be worn for the follow up visit. There will be no additional fee for that visit.
_____ There will be office visit fees for patients that want to be refitted in a different brand of contact
lenses after the initial visit. This will also apply to patients who return to the office for a follow up
after 2 months of the exam.
*Please advise us if you are interested in color contact lenses.
If you have any questions, please do not hesitate to ask.
Thank you,
20/20 Eye Care