Contact Lens Patient Agreement – Custom Eyes Lee’s Summit (Custom Vision, Inc., DBA Custom Eyes)

Name: CustomEyes
Address: 3660 NE Ralph Powell Rd, Lee's Summit, MO, 64064, US
Telephone: 816-524-7400
Price range: $000 - $300

Please choose your location
Q: Why is there a contact lens evaluation fee in addition to the standard eye exam fee?
A: Contact lens patients require additional testing and monitoring over and above what is done during a routine eye exam. Contact lenses are medical devices and even though they may feel fine, there are health risks that must be taken seriously. Contact lenses may cause significant vision loss and blindness. Some patients may feel that since they have worn contacts for years or even decades this is not a necessary process. These eyes are at an even higher risk of long term effects from contact lens wear so this step is as necessary if not even more so.
Remove your contacts immediately and call us if:
1. Your eyes become red or painful
2. You experience any change or decrease in vision
3. You suspect something is wrong
In 2004 contact lenses were classified as medical devices by the FDA. Therefore, a fitting must be performed to ensure the accuracy and safety of the contacts to the patient. In addition, the FDA has required that a fitting be done on an annual basis regardless if the patient has worn contact lenses in the past. Therefore, a contact lens prescription has to be given by the doctor that is only good for one year.
CONTACT LENS FITTING FEES:
Standard Fit | Varies with complexity of fit with 1-2 visits included | $49-$79
Advanced Standard Fit | Varies with complexity of fit with up to three visits included | $79-$99
Specialty Fit | Varies with complexity of fit with up to six visits included | $79-$1200
Contact Lens New Wearer Lesson | $20
- The cost of your annual exam is not included in the above quoted fees.
- Many insurance plans do not cover the full cost of the contact lens fees. You will be responsible for any uncovered costs.
- Patients must return for follow-up visits as instructed to obtain a contact lens prescription. These visits are to ensure the proper fit of the lenses and to protect the health of your eyes.
- Contact lens prescriptions expire one year from the date of the initial exam.
- There is no charge for follow-up visits during the first 90 days or first 3 follow up visits, whichever comes first.
- Any visit after ninety days will be charged at regular office visit rates.
NOTICE: If purchasing a one year supply of contacts shipping is free to your home or office. There is a $9.00 shipping fee if not ordering an annual supply
How would you like your prescription?*
- Paper
- Electronic (If electronic it will be sent to you through unencrypted email which is not secure and does not guarantee privacy. Do you still want it sent to you electronically?)
*
I have read and understand the information and agreement for contact lens services at Custom Eyes.
Patient Name*
First Last
Patient Signature
Date
MM slash DD slash YYYY

CONTACT LENS FITTING FEES:

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