CRT Service Agreement Form

Welcome to our Corneal Reshaping Therapy (CRT) treatment program. You are beginning an exciting program designed to reduce and/or eliminate your dependence on eyeglasses or contact lenses during the day by reducing or fully correcting your myopia (nearsightedness).

Corneal Reshaping Therapy involves the use of highly specialized contact lenses to be worn during sleep that will gently and non-surgically reshape your corneas as you sleep. The goal is to remove the lenses upon awakening to allow for clear uncorrected vision during the waking hours. The sophisticated process requires an extensive evaluation beyond a comprehensive eye examination and can only be conducted by a certified CRT practitioner. The process includes a thorough analysis of refractive error (prescription measurement), eye health, corneal size, shape and curvature (via corneal topography) and diagnostic evaluation to determine the proper lenses that will provide non-surgical corneal reshaping resulting in improved, unaided vision.

TREATMENT PROTOCOL
The length of time to achieve your full treatment will be primarily determined by your prescription and your compliance with the prescribed CRT wearing schedule. Typically, we expect to see 90% of the vision changes within the first week of treatment and full treatment within two weeks. Some eyes will require a longer period of time to complete the process. During the time that full correction is yet to be reached, patients may wear their CRT lenses or disposable soft lenses during the daytime to maximize clarity of vision. Even once full treatment is reached, the CRT lenses will have to be worn routinely each night to maintain clear uncorrected daytime vision.

PROFESSIONAL FEES
The fee for CRT includes all professional services and all CRT therapeutic lenses that are required to complete the treatment up to one year from the date of the initial fitting. The fees discussed in this agreement will cover your Corneal Reshaping Therapy treatment until one year from the date this document is signed.

The $1100 CRT service fee includes:

· the initial CRT evaluation, corneal topography, and diagnostic fitting analysis

· 1 day follow up evaluation and topography

· 1 week follow up evaluation and topography

· 6 month follow up evaluation and topography

· additional follow up visits as necessary

The $700 CRT material fee includes:

· initial pair of therapeutic lenses

· additional lenses necessary for treatment enhancement, eye health or comfort within 90 days (provided upon an exchange with the initial lens). This does not cover loss of lenses

· temporary soft disposable lenses that may be necessary until full correction is achieved

NOTE: Replacement lenses for lost, damaged, or spare lenses will cost an additional $350 per lens.

We recommend that you always have a spare pair of lenses. We can offer a spare pair of lenses for 50% off within the first 90 days of the initial fitting. Treatment may be compromised if disrupted by discontinued wear due to lost or damaged lenses.

The total $1800 fee must be paid in full before your Paragon CRT therapeutic lenses are dispensed. This fee may be handled with cash, check, credit card, or through our convenient patient financing program.

CONTINUING CARE

As with all contact lens wearers, routine follow-up evaluations are required to maintain proper eye health and visual functioning. After the first year of CRT, you will need to be evaluated every 6 months for corneal topography, contact lens fit assessment, and vision evaluation. This will cost $155.00 per year in addition to your comprehensive examination fees. Also, CRT lenses will need to be replaced annually at a cost of $350/lens.

CANCELLATION POLICY

It is a rare occurrence in health care that every procedure succeeds in every case. If there is a need or desire to discontinue CRT, the fees shall be adjusted whether the decision to discontinue is made by either the Patient or the Provider within the term of the agreement. Fees for a non-discounted case will be refunded on the prorated basis shown below*:

Discontinue within 2 weeks: Refund of $1500 upon return of CRT lenses**

Discontinue after 2 weeks but before 90 days after initial fitting: Refund of $1000 upon return of CRT lenses**

*Any discounts from insurance or other programs will not be included in a refund to the patient.

**Fees for lost, damaged, or non-returned lenses will not be refunded (at a rate of $350/lens).

PATIENT RESPONSIBILITIES

1. Follow all verbal and written contact lens care and wearing instructions given by your certified CRT practitioner.

2. Attend all scheduled appointments.

3. Use only the prescribed lens care system.

4. Comply with the prescribed wearing schedule for the lenses.

Report all treatment related emergencies immediately.

I understand that this procedure is designed to change my vision through corneal reshaping. There is no guarantee that my uncorrected vision will improve following Corneal Reshaping Therapy.

Please initial here

I understand that I will experience altered vision through my current eyeglasses and/or contact lenses due to the change in corneal curvature as a result of Corneal Reshaping Therapy.

Please initial here

I understand that the therapeutic effect of CRT willdecrease if the lenses are not continued to be worn everyday.

Please initial here

I understand it is my responsibility to read and understand the package insert “Considering Contact Lens corneal Refractive Therapy?”that is included with this information.

Please initial here

I understand and agree to seek immediate care by calling (614) 898-9989 during regular hours or following the prompts to contact the on-call doctor after hours, should I experience eye pain, excessive redness, light sensitivity, excessive tearing or discharge, or a sudden loss of vision.

Please initial here

I have read and understand the above, and I am in complete agreement with the contents of this agreement. The undersigned here by agree to the terms of this agreement and agree to perform their responsibilities in an effort to achieve optimum success in the Corneal Reshaping Therapy treatment.

Patient Name

First NameLast Name

Date

Corneal Reshaping Therapy Agreement and Informed Consent