Patient Enrollment Form

Patient Registration

Please fill in the form below
Name*

First Name Last Name
Date of Birth*
MM/DD/YYYY
Sex*
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number:*
E-mail*
example@example.com
In case of emergency...
Emergency Contact:*

First Name Last Name
Relationship*
Contact Number*

Reason For Visit

Please fill in the form below
Please select your appointment type*
What is the primary reason for this visit?*

Allergies
Are you allergic to any of the following?*

Food: NutNo known drug allergiesBee stingsNo known other allergiesEnvironmental/SeasonalNo latex sensitivityLatex sensitivityOther, please specify

Social History

Please fill in the form below
Do you drink alcohol?*

YesNo
Tobacco use ?*

Heavy Tobacco SmokerLight Tobacco SmokerFormer SmokerNever smoked

Contact Lens Prescription Renewal Policy

Please fill in the form below
To purchase contact lens materials its required by law to have an active contact lens prescription. This applies to all patients, even though you may have worn contact lenses in the past and/or even if the prescription does not change. The state of Georgia requires that a contact lens evaluation be performed every 12 months to renew contact lens prescriptions.

To comply with contat lens wearer laws your contact lens prescription will be issued right after the contact lens examination via the Dr. Contact Lens Portal. If trials need to be ordered we strongly advised to postpone ordering any contact lens supply until satified with the issued lenses. And if you are not fully satisfied with dispensed or ordered trial lenses its impeartive that you schedule a contact lens follow up as soon as possible. Contact lens follow-ups must be perform with in 45 days of initial exam to avoid extra charges and its the patients responsibility to schedule them if needed. Addition fee's are listed below. There are certain patients that use specialty lenses and those prescriptions will be issued to the email provided. If a patient requires multiple contact lens prescriptions, fittings or evaluations, additional charges will apply. Payment for contact lens evaluations to renew contact lens prescriptions, as well as with all other professional fees, is non-refundable.

CONTACT LENS EVALUATION FEES are based on the complexity of evaluation.

Soft Standard Fitting	$60
Soft Extended Wear Fitting	$80
Soft Color Fitting	$80
Soft Astigmatism Fitting	$80
Soft Monovision Fitting	$90
Soft Multifocal Fitting	$90
Hybrid Standard Fitting	$135
Hybrid Multifocal Fitting	$155
Hybrid Keratoconus/PS Fitting	$215
Gas Permeable Standard Fitting	$120
Gas Permeable Premium Fitting	$150
Semi Scleral Fitting	$350

The contact lens evaluation fee is non-refundable and only includes up to two follow-up visits within a 45 day period from the initial exam. If additional visits are needeed, additional fees will apply.

ADDITIONAL FEES

Additional 20 minute training session	$29
3rd visits or if it's after the 45 day period	$29
For visits 3 months after initial exam	$68
For visits after 6 months from initial exam	Full Exam Cost

Return Policy

If you purchased contact lenses from our office and are dissatisfied for any reason with the purchase materials, the following polices will apply.

Certain, soft contact lens boxes can be returned for credit or refunded within 60 days of purchase. As long as the boxes are unopened, undamaged, and unmarked.

Furthermore, if boxes are returned and a courtesy diagnostic lenses were supplied at the time of purchase, a dispensing fee will apply.

Certain toric (ex: XR lenses), color (BioColors, Eyedia) and custom lenses are non-refundable once the order has been placed.

Gas Permeable, scleral, hybrid, and some soft contacts are made to order and can also be returned within 60 days, but a $35 re-stocking fee per lens is required depending on lens type, manufacturer and design.

If lenses were shipped to home and do not arrive in the expected time; we need to be notified immediately. As with any return, exchange or claim needs to be submitted to distributor and manufacturer within 60 days of order for investigation.

Lastly, if any contact lens product is not picked up within 6 months of inital order and we are not able to establish communication; the lenses will be destroyed as no refund would be issued as they would have exceeded the 60 days period for any returns from manufacturer or distributor.

I give consent to have a contact lens fitting/evaluation to renew a contact lens prescription and understand that the fee will vary depending on complexity.*

YesNo
Acknowledgement of The Fairness to Contact Lens Consumers Act.*

By checking this box I acknowledge that I will receive a digital copy of my contact lens prescription to the email (and/or text) provided instead of a paper copy via Dr.Contact Lens portal. If I am not satisfied with finalized contact lens prescription, a follow up visit can be scheduled at no charge within 45 days of initial exam, if needed.
Signature*

Clear
Should be Empty:

	None	Father	Mother	Brother	Sister	Son	Daughter
Hypertension
Cancer
Diabetes

	None	Father	Mother	Brother	Sister	Son	Daughter
Glaucoma
Macular Degeneration
Amblyopia

Patient Registration

Reason For Visit

Medical History

Medications

Allergies

Past Ocular History

Social History

Family Medical History

General Consents

Contact Lens Prescription Renewal Policy