Amanda Brenci, O.D.
1187 John Sims Pkwy
Niceville, FL 32578
As with any medical drug or device, the use of daily wear or extended wear contact lenses is not
without risk. A small but significant percentage of individuals wearing contact lenses develop
potentially serious complications, which can lead to permanent eye damage.
If you have any of the following, remove your contacts and make arrangements to see your eye care
professional before wearing your contacts again:
EYE PAIN OR REDNESS WATERING OR DISCHARGE OF THE EYES
CLOUDY OR FOGGY VISION INCREADED SENSITIVITY TO LIGHT
Dr. Brenci may require a 1-2 week follow-up visit. This visit is included in the cost of the eye exam. At
this visit, she will evaluate the performance of your contact lenses and finalize the contact lens
prescription. Your exam is not complete until this visit. You will be unable to
purchase any additional contact lenses until this visit is completed.
All contact lens follow up visits will be included in the initial fitting fee for 6
VISITS following your initial contact lens exam. There will be an office charge of
$39.00 for any follow-up visits that are not completed within 45 days of your
initial exam. After 3 months, you be required to undergo a new eye exam if your
follow up care has not been completed.
It is imperative that you remove your daily wear contact lenses every night for cleaning and
disinfection. Use only the multi-purpose disinfecting solution prescribed by Dr. Brenci. Please have
your contact lenses in your eyes when you arrive for your follow-up visit. If you
have a lost or torn lens, please inform the office before your appointment, so it
may be replaced. Your contact lens prescription expires in one year. A new contact lens
exam will be required at the time to purchase new lenses or receive additional trial lenses.
By my signature, I acknowledge that I have read this document and will comply with all recommended
Patient or Guardian Signature Today’s Date
Dispose of your contacts every: DAY 2 WEEKS MONTH
Daily Wear Only Daily or Overnight Wear Solution: _________________________________
Wear Time: ______ 4 HOURS ______ 8 HOURS ***RECOMMENDED EYE DROPS***
______ 4 HOURS ______ 8 HOURS
______ 6 HOURS ______ 10 HOURS OPTIVE
______ 6 HOURS ______ 10 HOURS REFRESH FOR CONTACTS
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