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? *

Social History

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

Yes No
Tobacco use ? *

Heavy Tobacco Smoker Light Tobacco Smoker Former Smoker Never smoked

Contact Lens Fitting/Evaluation Policy

Please fill in the form below
In order to maintain eye health, the state of Georgia requires that a contact lens evaluation be performed every 12 months to renew contact lens prescriptions. 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.

Contact lens prescriptions will be e-mailed to the e-mail provided only after a successful evaluation has been achieved. 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. If a patient requires multiple contact lens prescriptions, fittings or evaluations, additional charges will apply. Payment for contact lens evaluations, 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.

Soft contact lens boxes can be returned for credit or refund 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, color, and custom lenses are non-refundable.

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.

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

Yes No
Acknowledgement of The Fairness to Contact Lens Consumers Act. *

I agree to receive my finalized contact lens prescription via the e-mail provided once the contact lens evaluation has been completed. If not satisfied with finalized contact lens prescription, a follow up visit can be scheduled by patient at no charge within 45 days of initial exam, if needed.
Signature *

Clear
Should be Empty:

	None	Father	Mother	Brother	Sister	Son	Daughter
Diabetes Mellitus
Cancer
Hypertension

	None	Father	Mother	Brother	Sister	Son	Daughter
Macula
Glaucoma
Amblyopia

Patient Registration

Reason For Visit

Medical History

Medications

Past Ocular History

Social History

Family Medical History

Consents

Contact Lens Fitting/Evaluation Policy