Myopia Care Program
Soft Contact Lenses 1 Year Agreement

Soft Contact Lenses 1 Year Agreement

  • MM slash DD slash YYYY
  • ’s Myopia Care will be 12 months in length and the program fee is
  • This is a one-time fee. During this time, our specialty lens team will work together to provide
  • with the most customized care for their myopia management needs
  • The First Year Program Fee Includes the Following:

    • Initial fitting and evaluation of custom lenses
    • ALL lens changes made by the doctor within the first 12 months
    • Unlimited follow-ups; typically includes approximately 6-8 visits
    • ALL topography, ultrasound and vision testing
    • ALL training on insertion and removal of lenses
    • 24/7 communications necessary between parent/patient and staff/Doctor
    • Behavioral coaching through emails/messages that help parent & patient implement natural behavioral changes needed to support myopia management at home
  • Looking Ahead: Year 2 and beyond: We offer a Myopia Care Maintenance Program which includes:

    • ALL Myopia Care follow up appointments
    • ALL topography, ultrasound and vision testing as needed
    • A comprehensive eye exam
    • Any additional training & learning
    • Behavioral coaching messages to support natural changes of behavior in the home
  • is maintenance program fee, for 12 months.
  • fee will be, If you exceed the 12-month period. This does NOT include a new pair of lenses if the lenses need to be replaced. Any medical care during this period will be treated separately and your medical insurance rules will apply.
  • Initial consultation with the doctor, this service fee is
  • Contact lens supply. Lenses come in quarterly or in 6-months’ supply, depending on the lens design chosen to best suit the needs of
  • If rare circumstances prevent you from continuing your treatment during the first three months of care, we will gladly refund all fees paid, less
  • Program Requirements:

    • Be on time. Arriving late will create the need for your appointment to be rescheduled.
    • When you need to cancel or reschedule an appointment, inform us at least 48 hours before the appointment. A fee will be imposed if insufficient time is given.
    • Do the homework and preparation that is needed for maximum success for the program including viewing training videos and reading materials
  • This program outline is valid until

  • after this time, The examination data collected becomes outdated and an additional consultation is needed
  • All additional consultations carry the same fee as the consultation fee
  • I have read, understand and agree to the terms noted above.

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  • Dual Focused Soft Lenses

    Consent

  • Dual Focused Soft Lenses

    You are being fit with soft, dual focused contact lenses. These custom designed soft lenses shift the image received by the eye so that the image falls on the retina and reduces any peripheral blur, thus slowing the rate of progression. The lenses must be worn on a daily basis to receive the full benefit.

  • Complications and Side Effects

    Dual focused soft lenses carry the same risks as other types of contact lenses, such as swelling of the cornea, scratching of the eye, irritation, infection, unusual eye discharge, excessive tearing, dry eyes, sensitivity to light, pain, redness, and distorted vision. These risks are usually temporary if the contact lenses are removed promptly and if appropriate professional care is received. In some instances, permanent corneal scarring, infection or blood vessel growth on the cornea may occur, which can lead to reduced sight in rare cases. Although uncommon, infection of the cornea can develop rapidly and lead to loss of vision. The risk of infection of the cornea has been shown to be greater among patients who wear their lenses overnight than among those who do not sleep in their lenses.

    I have read and fully understand the above information. I agree to adhere to the wearing and follow-up schedules as prescribed. If I fail to return for my scheduled follow-up visits, I may forfeit my chance to continue wear of dual focused soft contact lenses. All of my questions concerning my eyes and contact lenses have been answered to my satisfaction.

  • (Parent to sign if patient is under 18 years of age)
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