Patient Acknowledgement of TotalVision Eyecare of Glastonbury Contact Lens Policy

Contact lenses are medical devices which are regulated by the U.S. FDA. Wearing contact lenses involves risks of serious adverse effects to the health of the eye and may result in ocular damage and permanent loss of vision. Contact lens examinations are required on a yearly basis.

√I have been instructed in the proper methods of insertion, removal, use, wearing schedule and care for my contact lenses; I have been provided with the correct products to clean, disinfect and store my lenses. √I have been given a copy of the TotalVision EyeCare of Glastonbury Contact Lens Evaluation Information. √I understand that follow-up care is important and plan to keep my appointments. √I realize that it is rare but possible for contact lenses to cause irreversible eye damage or even blindness due to infections or unexpected adverse reactions. These are usually, but not always, due to over or improper wear, unsanitary habits, inappropriate use of solution, and/or failure to use fresh solution every day. I understand that by ignoring pain, irritation or other symptoms I may be putting my eye health and vision at risk. √I will not sleep in my contact lenses unless instructed, and will remove them if I experience dryness, redness, irritation and/or pain. √If I have unusual eye irritation, prolonged redness, loss of clear vision or pain, I will remove my lenses and call the office at (860) 659-5900 or go to the nearest urgent care center or hospital emergency room. If I obtain care outside of the office, I will notify the office as soon as possible. √I understand that my annual Comprehensive Eye Health Examination and my annual Contact Lens Evaluation are two separate charges. √I understand that the Contact Lens Evaluation may not be covered by my insurance or vision plan, and that all services rendered today will require payment in full. Fitting fees include diagnostic contact lenses when indicated and up to 90 days of follow-up care at no additional charge. Consultations after 90 days will be billed at our standard consultation rates. √Visits for red eyes and infections are considered medical care, and are not included in the Contact Lens Fitting & Evaluation. These will usually be covered by your Medical health insurance (subject to copays and deductibles), but not by any routine vision plan such as VSP or EyeMed.

√I have been instructed in the proper methods of insertion, removal, use, wearing schedule and care for my contact lenses; I have been provided with the correct products to clean, disinfect and store my lenses.

√I have been given a copy of the TotalVision EyeCare of Glastonbury Contact Lens Evaluation Information.

√I understand that follow-up care is important and plan to keep my appointments.

√I realize that it is rare but possible for contact lenses to cause irreversible eye damage or even blindness due to infections or unexpected adverse reactions. These are usually, but not always, due to over or improper wear, unsanitary habits, inappropriate use of solution, and/or failure to use fresh solution every day. I understand that by ignoring pain, irritation or other symptoms I may be putting my eye health and vision at risk.

√I will not sleep in my contact lenses unless instructed, and will remove them if I experience dryness, redness, irritation and/or pain.

√If I have unusual eye irritation, prolonged redness, loss of clear vision or pain, I will remove my lenses and call the office at (860) 659-5900 or go to the nearest urgent care center or hospital emergency room. If I obtain care outside of the office, I will notify the office as soon as possible.

√I understand that my annual Comprehensive Eye Health Examination and my annual Contact Lens Evaluation are two separate charges.

√I understand that the Contact Lens Evaluation may not be covered by my insurance or vision plan, and that all services rendered today will require payment in full. Fitting fees include diagnostic contact lenses when indicated and up to 90 days of follow-up care at no additional charge. Consultations after 90 days will be billed at our standard consultation rates.

√Visits for red eyes and infections are considered medical care, and are not included in the Contact Lens Fitting & Evaluation. These will usually be covered by your Medical health insurance (subject to copays and deductibles), but not by any routine vision plan such as VSP or EyeMed.

I agree with the above

I will replace my contact lenses every ______ day / week(s) / month(s) as directed by my optometrist.

By signing below I acknowledge that I have read and agree to the terms of the Contact Lens Policy at TotalVision Eyecare of Glastonbury, and that I all my questions have been answered.

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