Contact Lens Rx Acknowledgement Form

Contact Lens Rx Acknowledgement Form

The Federal Trade Commission (FTC) recently issued a ruling requiring contact lens providers to provide a printed or digital copy of contact lens prescriptions to patients upon completion of a fitting. Additionally, the patient must sign a form stating that they have received this prescription. Please complete and submit this form if you wish to receive a copy of your prescription and be sure to select how you would like to receive it. We appreciate your patience and understanding as we implement these new procedures.
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
Included below is important information to review prior to receiving your contact lens prescription:

The Center for Disease Control and Prevention (CDC) states: “Contact lenses can provide many benefits, but they are not risk-free – especially if contact lens wearers don’t practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment.”

The CDC recommends the following for contact lens wearers:
1. Schedule a visit with your eye doctor at least once a year
2. Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision
3. Understand that eye infections that go untreated can lead to eye damage or even blindness
The Food and Drug Administration (FDA) indicates:
1. “To be sure that your eye remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It’s safer to be re-checked by your health care professional.”
Symptoms of eye infections include:
- Irritated, red eyes
- Worsening pain in or around eyes, even after contact lens removal
- Light sensitivity
- Sudden blurry vision
- Unusually watery eyes or discharge
How you would like to receive your prescription? *

Electronically (emailed) Paper copy (picked up or mailed)
Email Address *
example@example.com
By signing below, I acknowledge that I have received a copy of my contact lens prescription at the completion of my fitting; I understand this prescription is valid for one year.
Electronic Signature of Patient, Parent, Guardian, or Personal Representative *

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Today's Date *

Month Day Year
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