Contact Lens Wearer’s Agreement

Name: Monroe Vision Associates
Address: 337 Applegarth Rd, Monroe Township, NJ, 08831, US
Telephone: 609-655-2666
Price range: $000 - $300

I would like to inform you of my office policy regarding contact lens care. It is my goal to provide comfortable, clear vision with contact lenses while maintaining excellent ocular health. Please read the following agreement carefully.
- The Doctor’s professional fees for the contact lens exam includes: the initial exam, initial cleaning kit, instructions on lens care, instructions on insertion and removal of the lenses and routine follow-up exams as determined by the doctor during the first three (3) months (generally 3 follow-up visits plus an evaluation at the time you pick up your contact lenses). Fees are per visit thereafter. The price for contact lenses are not included in Dr. Donlon’sor Dr. Bubnovsky’s professional fee.
I understand that the examination and contact lens fitting fees, and solutions are non-refundable. Most insurance companies do notcover a contact lens fit or yearly contact lens evaluation fee. I also understand that my insurance covers a routine eye exam only and Iwill be charged a contact lens fitting / yearly evaluation fee appropriate for the type of contacts necessary for my eyes (fitting fees canrange from $120-300 and for the Annual (yearly) CL evaluation). All fees are in addition to the routine eye exam fee). Please askthe Doctor or receptionist any questions you may have regarding specific contact lens exam fees before you see the Doctor. AllDoctor exam fees must be paid before ordering your yearly supply or leaving the office with any trial contacts. Please answer yes or noto the following:
New Contact Lens Wearer SV l $160 Toric Monovision $180 Multifocal & RGP $240 Specialty fit $200-1,800
Previous Contact Lens Wearer SV $130 Toric Monovision $150 Multifocal & RGP $170 Specialty fit $200-1,800
- I would like a contact lens fitting / annual CL evaluation. I understand the above fees are in addition to routine copays.
- I would not like a contact lens fitting / annual contact lens evaluation today but will reschedule within 2 months from Today. After 2 months, the CL exam fees will range from $ 150-500.
- Successful wearing of contact lens is largely dependent on proper care, handling, routine follow-up care and examinations. I understand the importance of follow-up examinations and keeping appointments for these necessary progress visits. These periodic evaluations are scheduled to assure proper fit of my contact lenses and more importantly the continued good health of my eyes. I also understand that I must personally pick up my contact lenses in person in order for Dr. Donlon to check my eye health and proper fit of my contacts. Knowing this, I agree to keep all progress visits and failure to do so relieves Dr. Donlon of any responsibility/ liability regarding my ocular health and vision.
- I have been instructed in proper care and cleaning of my lenses and received a care kit. I have also been instructed in the proper techniques for insertion and removal of my contacts and can do so independently. I understand that I should never change brands of solutions without approval of Dr. Donlon
- Contact lenses are a medical device and not just a convenience. Improper use, failure to show up for progress visits, wearing unclean, unsterilized contact lenses that are torn, damaged or coated with film may cause permanent vision loss or other complications that may prevent you from ever wearing contact lenses again. If at any time my contact lenses feel uncomfortable, my eyes become red, painful, irritated or sensitive to light, or my vision becomes blurry while wearing my contacts I will immediately remove the contacts and notify Dr. Donlon or Dr. Bubnovsky.
- The contact lens prescription expires one year from the date of the initial fitting. Replacement contact lenses cannot be ordered after the one year expiration date. I agree to be re-examined every year in order to ensure optimal ocular health of my eyes and fit of the contact lenses. I also understand that regardless of my insurance eligibility that covers routine eye examinations, I still must have a contact lens examination every year in order to obtain optimal ocular health.
We thank you for your attention regarding this Contact Lens Wearer’s Agreement. Please feel free to email us at appointmentdesk@monroevisionassociates.com with any questions regarding this agreement or call us at Cranbury office at (609) 655-2666 or the Spotswood office (732) 251-8166. If you would like a further explanation, ask Dr. Donlon or Dr. Bubnovsky at the beginning of your appointment.
Name
First Last
Signature
Date
MM slash DD slash YYYY