Contact Lenses Form Optometrists in Wallingford, CT

Patient Consent Form for Electronic Delivery of Contact Lens Prescription

*Please be aware trials provided at our office are for patients who order through our office only. We are not responsible for damaged/defective contacts from a 3 rd party *

I hereby consent to receive my contact lens prescription electronically. I understand that this electronic delivery is in accordance with the Federal Trade Commission (FTC) rules, which requires the doctor to obtain consent for electronic transmission of prescriptions.

I understand that by providing my consent, I will receive my contact lens prescription via email, secure online portal or other electronic delivery method.

I have read and understood the information provided and consent to receive my contact lens prescription electronically.

Patient Name:

Date of Birth:

Patient or Guardian Signature:

Date:

Included below is important information to review prior to receiving your contact lens prescription:

Do not overwear contact lenses, wear them only as long as the doctor has prescribed. Dailies should only be worn once, bi-weekly for two weeks, and monthly for one month (the starting date is the date that the contact lenses are opened).
Be sure to wash your hands thoroughly before touching or handling contact lenses to avoid getting bacteria in the eye or lens.
Disinfect the contact lenses with the correct contact lens solution before reusing or placing them back into the case.
Always have a pair of glasses to wear to give your eyes a break, as contact lenses are considered a foreign body and can aggravate the eye with overuse.
Immediately remove your contact lenses and wear your glasses if you are experiencing any pain, discomfort, sensitivity, or sudden blurriness, and call the office if the problem persists.
Proper contact lens care is crucial to avoid eye injuries including ulcers, loss of vision, and even blindness.
Schedule Routine Yearly Exams to keep the proper health of the eyes.