CONTACT LENS POLICY

 The fitting of contact lenses is an exacting procedure and the lens specifications and
 fittings require additional testing. The contact lens fitting fee is not included in the medical
 eye examination.

In order to ensure you receive the highest quality medical eye care, fitting and follow-up
procedures our contact lens policy is as follows:

        The fitting fee is separate from the medical eye examination. This fee is generally
         not covered by insurance and will be your responsibility.
     •   We promise that we will do the best that our knowledge, skill and time, can
         accomplish. No other guarantee will be made.
        All patients require an annual medical eye examination before the contact lens
         prescription can be renewed. This is stipulated by Georgia State statute.
        The contact lens prescription will be released only after you have presented for a
         follow-up examination and no eye problems are detected and a release form is
         signed. A contact lens prescription is valid for one year (Georgia Law).
     •   The contact lens fitting fee includes a pair of trial lenses, a starter kit of solution
         and the follow-up examination, which must be done within the first month. If
         additional follow-up visits are needed, there will be no charge for the first two
         additional visits with our contact lens technician however thereafter there will be a
         charge at the normal office rate.
        If for any reason, the fitting is terminated during the first sixty days and the lenses
         are returned in sealed boxes (not individual sealed lenses), a refund for the lenses
         will he given but not for the fitting fees incurred.
        Because every contact lens has the potential to cause damage to the front part of the
         eye, it is understood and agreed that six months after the fitting has been
         completed,, you will return to the office for a check-up of the lenses and a cornea

         check. The fee for this brief office visit is not covered by vision insurance.

This policy enables us to provide you with the highest standard of medical eye care. We
 welcome the opportunity to serve you however, for the safety of your vision we will not
 make exceptions to this policy.


Name:                        ___________

Signature: _______________________                     Date:                                  _

                                                                                 Rev. 12/10

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