Contact Lens Compliance Agreement
I am a first time contact lens wearer. I have received a training form and instructions on how to properly insert, remove, and handle contact lenses.
I have worn contact lenses previously. I am fully aware of the insertion, removal, and handling techniques of contact lenses.
I understand that the contact lens evaluation is an additional option to my routine eye exam and may not be fully covered by my insurance plan. A contact lens is a medical device that requires additional annual testing. The fee for a contact lens evaluation will be determined by the type of contact lens that is required for my prescription.
I agree to follow the instructions given to me by this sheet, the doctor, and the dispensing staff. I understand that my cleaning and wearing schedules are very important in maintaining my contact lenses and the health of my eyes. I understand that improper use of my contacts can lead to permanent vision loss. I also understand that by wearing contacts I am increasing my risk for eye infections, allergies, and other eye complications, that can lead to blindness or vision loss.
I am to remove my contacts immediately and call my eye doctor if:
1) Unusual burning, irritation, redness, pain, or watering of the eyes occurs
2) I suspect something is wrong
3) Unusual blurred vision
Wear schedule for first time wearers in
My Contacts are: 2 week and monthly lenses:
To be removed every __________________________ Day 1: _________________________________
Day 2: _________________________________
To be disposed every ___________________________
Day 3: _________________________________
To be cleaned and rubbed with ____________________________ Day 4 & Beyond: _________________________
By signing below, I understand and agree to all the terms outlined on this form. I also have received a copy of this form for my reference.
__________________________________ ______ ________________________
Signature of Patient, Parent/Guardian Patient’s Printed Name
Initials of Signature Eye Care Staff Date