Download CLAgreement - The Eye Site, PC

The Eye Site, P.C.
Stephanie Ommen, OD
504 South Mulberry Avenue, Butler, Alabama 36904
phone: 205.459.7483 (SITE)
fax: 888.848.1202
www.facebook.com/theeyesitepc
Corneal Health & Contact lens Design & Power Analysis Annual Agreement
At The Eye Site, PC, we carry the latest in contact lens technology and specialize in fitting standard, astigmatismcorrecting, multifocal, and therapeutic contact lenses. We are dedicated to your eye health, as well as an enjoyable,
comfortable contact lens experience.
A Contact Lens Initiation and Evaluation fee is necessary to begin as a new wearer or to renew the current contact
lens prescription and is in addition to a comprehensive eye examination fee. This evaluation will include precise
measurements, analysis of your vision needs, and recommendations specifically tailored for you. It may also
include the use of diagnostic lenses if necessary by our doctor, as well as follow-up visits, to ensure the proper fit
of the lenses and good ocular health. This program requires monitoring by the doctor; therefore, the contact lens
prescription is not available until the follow-up period is complete.*
The evaluation fee will range in price depending on the complexity of contact lenses worn and is as follows:
Standard (Soft, Spherical)
$ _________
Superior (Soft, Multifocal)
$ _________
Advanced (Soft, Toric)
$ _________
Medical**
$ _________
*Our doctor reserves the right to terminate the agreement upon non-compliance.
**Follow-up visits may not be included in the Medical fits
This fee will cover the initial evaluation and all contact lens related follow-up visits up to 3 (three) visits within 1
month. Prescriptions may be finalized on the initial exam if the doctor and patient agree, and the patient may
return within one week for a power adjustment; however, all contact lens material sales are final. If necessary, it
will include the cost of any additional contact lens training classes for those individuals needing contact lens
instruction on insertion, removal, and lens care at the time of the initial fitting. If you are unable to return for a
follow-up appointment within 1 month from the initial visit and we need to order additional trials, there will be a
shipping fee per order. If the prescription is already finalized or the time period has exceeded 1 month, a reevaluation fee will be charged as deemed necessary by The Eye Site, PC. Contact lens prescriptions are valid for a
period of one year from the finalized encounter, unless otherwise noted by the doctor.
I agree to this policy and understand the potential risks and adverse reactions. I have no further questions.
Patient Signature: __________________________________ Date: __________________
Printed Name: _____________________________________________________________