Corneal Refractive Therapy (CRT) Consent Form

Fees:

	Initials of Patient or Legal Representative
CRT is based on a total fee for the first year of treatment. It includes office visits and contact lenses used within the time frame of the first year. The cost of these specialty contact lenses may be partially covered by vision insurance. Annual follow ups after the first year of service will be $150 (subject to change), plus the yearly purchase of the new CRT contact lenses.
The day of the initial CRT fitting the first installment of $470 is required.
Lost or damaged contact lenses will be replaced for a fee of $235 per lens. NO EXCEPTIONS.
Appointments will be made as often as necessary to accomplish our goal. The fee for your total CRT Program depends on your prescription. This fee includes all prescribed contact lenses and all related professional services for the first year of treatment.

Nearsighted rage from -0.50 to -2.00 : $1,256.54*

Nearsighted range from -2.25 to -6.00 : $1,570.68*

Astigmatism range greater than 1.00D : $1,656.55*

*taxes included

ONE MONTH NO-FAULT GUARANTEE

	Initial of Patient or Legal Representative
For any reason, if the patient or parent/guardian does not like the procedure, a full refund, minus $470 (the cost of the lenses) will be credited. After the first month, no refund will be offered.
Upon receiving each new set of lenses during the fitting process, you are required to return your previous set. Please remember to bring them with you. You will be charged for any set of lenses you do not return.
United States federal laws consider contact lenses to be a medical device; therefore, patients MUST FOLLOW the doctor’s lens care instructions. If the patient experiences any discomfort/pain, red eye, and/or discharge, he or she must discontinue lens wear immediately and contact the doctor or an available licensed optometrist.

I have read and understand the above conditions and I will comply with the accordance and contents.

Signature of Parent or Legal Representative*

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Date*

If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.

Name of Legal Representative

First NameLast Name

Relationship to Patient