Laurie L. Sorrenson, O.D., FAAO Susan Shauger, O.D. Kim Marez-Slaughter, O.D. Dipa M. Kodukula, O.D. 12233 620N., Ste 103 Board Certified Therapeutic Optometrists Austin, TX 78750 www.lakelinevision.com (512) 918-EYES ANNUAL CONTACT LENS AGREEMENT SHEET
____ 1. Solutions prescribed by the doctor: A. Rinsing Solution ______$50 Gift Certificate for B. Disinfecting Solution ______all contact lens wearers for non-Rx sunglasses C. Lubricating Solution ______over $150 D. Enzymatic Cleaner ______2. We recommend sunglasses because UV light can cause cataracts, macular degeneration and pingueculae. ____ 3. Having the correct Rx in a pair of back-up-glasses is important in case of infection and to help keep eyes healthy. When purchasing a one year supply of contacts, you are eligible for a free frame from our value collection, when purchasing the pair of back-up-eyeglass lenses. * Insurance usually covers contact lenses or glasses, not both. ____ 4. Your fees today include the following: Comprehensive Eye Exam & Eye Health Evaluation ...... $ ______Annual Corneal health & contact lens design/power analysis . $ ______Optomap ...... $ ______TOTAL $ ____ 5. When you purchase contact lenses: YR Supply R L Contact Lens Per box ( ____ lenses) $_____|_____ Product ______
Total One Year (___ boxes) ______|_____ Less your insurance ______Ship to: Home TOTAL $ ______Office You Save $ ______
____ 6. If your Rx changes, we will exchange contact lenses purchased from us. Boxes must be resellable, i.e. no marks, no writing, no torn or missing labels and must be factory sealed. ____ 7. When you are down to your last month's supply of contact lenses, go to: "www.lakelinevision.com" and order your contacts by sending an email to "[email protected]" - Or you may call us. ____ 8. Wearing Schedule prescribed by the doctor: A. Daily Wear _____ hrs B. Extended Wear _____ days C. Disposables, throw away every ____ days ____ 9. Contact Lenses are medical devices which should be monitored by the doctor to determine the current prescription and health of the eyes to ensure successful contact lens wear. ____ 10. I understand that annual exams and sometimes 6 months corneal evaluations are necessary to continue replacing contacts. ____ 11. I understand that there is an increased risk of infection or corneal ulcers that can lead to loss of vision with contact lens wear. The risk increases if the contacts are worn extended wear. Complying with wearing times, care regimens and disposal schedules minimize this risk. ____ 12. I understand that if sudden or prolonged red eyes, pain or irritation occurs, I should remove the lenses and call this office immediately. ____ 13. Did the doctor answer all of your questions ?
Patient Signature ______Date ______Tech. Signature______
Print Name ______0917k9 RevL-AnnCLAgreement PrintShack- 512.345.1230