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CONTACT_LENS_AGREEMENT

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CONTACT_LENS_AGREEMENT Powered By Docstoc
					                                 Amanda Brenci, O.D.
                                    1187 John Sims Pkwy
                                     Niceville, FL 32578
                                       (850) 678-8876

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
follow-up instructions.

_________________________________________                            ___________________________
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
                                                                        BLINK FOR CONTACTS

				
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