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CONTACT LENS EXPERIENCE

Please complete the following form if you are a CURRENT lens userĀ NEW to our practice OR if you will be fit with contact lenses for the FIRST TIME. Completion of this form will assist in determining the most appropriate contact lens available for your prescription, ensuring that your comfort and visual needs are optimally met. If you are being fit with contact lenses for the first time, please select "NEW USER". Thank You.

First Patient's Name

First Name*

Last Name*
First Patient's Date of Birth*
First Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
First Patient's Signature*
Second Patient's Name

First Name*

Last Name*
Second Patient's Date of Birth*
Second Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Third Patient's Name

First Name*

Last Name*
Third Patient's Date of Birth*
Third Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Fourth Patient's Name

First Name*

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Fifth Patient's Name

First Name*

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Sixth Patient's Name

First Name*

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Seventh Patient's Name

First Name*

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Eighth Patient's Name

First Name*

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Ninth Patient's Name

First Name*

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Tenth Patient's Name

First Name*

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Contact Lens Experience

My Appointment is Scheduled on: *

Number of Years of Contact Lens Experience (New Contact Lens User please enter "0") *

Current Contact Lens Brand:
Frequency of Lens Replacement*
Maximum Wearing Time*
Vision With Current Contacts:*
Assessment of Comfort With Current Lenses:*
Cleaning Solution Used*
Solution Sensitivity:*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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