Contact Lens Patient Agreement


I am aware of other alternatives for the correction of my vision other than contact lenses. Even with proper care there are risks to wearing contact lenses, which include:

  • SOFT CONTACTS: irritation from solutions or protein build-up, conjunctivitis, corneal in shape of the corneal vascularization and severe and potentially blinding corneal infections and loss of eye.
  • RIGID CONTACTS: Intolerance, corneal swelling and or ulceration, corneal warping, change in shape of the cornea causing problems seeing well with glasses and irritation from chipped or broken lenses.
  • EXTENDED WEAR CONTACTS (WE DO NOT RECOMMEND OVERNIGHT WEAR OF ANY CONTACT LENSES): Risks include significantly increased risk of corneal ulcer and infection and severe and potentially blinding corneal infections and loss of eye. EXTENDED WEAR DOES NOT IMPLY “CONTINUOUS WEAR.

*I acknowledge that I have been properly instructed in the care of my contact lenses. I also understand that if I do not follow the instructions given for the care of my lenses, I put myself at risk to develop infections that can lead to the loss vision or even the loss of an eye.

*I also understand that poor care of my lenses may make them uncomfortable and not wearable and may increase the cost of my contact lens wear. I understand the fragility of contact lenses and that there is no warranty against damage of the lenses. Also, I have been instructed and have practiced insertion and removal of my lenses (if applicable).

*I understand that this contact lens prescription is valid for replacement lenses for ONE YEAR and that an annual exam and contact lenses exam will be required to update this prescription for replacement lenses after one year. I understand that if I do not have an exam after one year, then my risk of infection, discomfort or ruined lenses becomes greater as time passes.

*I understand that it is normal if at first:

  • My lenses itch or feel unusual
  • I feel one lens more at times
  • My vision seems fuzzier than with glasses
  • One eye sees better than the other

I will remove my lenses and call the office if:

  • I develop unusual pain or redness
  • I experience decreased vision that does not get better
  • I suspect something is wrong

I understand that if an eye infection, allergy, etc. occurs during a contact lens fitting the treatment of said eye infection, allergy, etc. will be billed to my medical insurance and I will be responsible for any copay under my medical insurance. I understand that full payment is expected at the times a contact lens fitting is performed.

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