Home ยป HIPAA PRIVACY POLICY/CONTACT LENS AGREEMENT

HIPAA PRIVACY POLICY/CONTACT LENS AGREEMENT

THE CONTACT LENS FITTING FEE INCLUDES ALL FOLLOW-UP VISITS FOR 30 DAYS.

 CONTACT LENS PRESCRIPTIONS WILL ONLY BE RELEASED AFTER THE INITIAL

FITTING PERIOD IS SUCCESSFULLY COMPLETED (WHICH MUST INCLUDE THE

EXAMINATION AND/OR  FITTING AND FOLLOW-UP VISITS).  AFTER 30 DAYS, IF NO

CONTACT LENS FOLLOW-UP HAS BEEN PERFORMED, OFFICE VISIT FEES WILL

BE APPLIED.

 

PATIENT SIGNATURE_____________________________________DATE________

PLEASE CONTACT OUR OFFICE FOR A COPY OF OUR PRIVACY POLICY.