Welcome to Precision Eye Care of NJ

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Do you wear glasses(Required)

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distance

reading

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Contact Lenses(Required)

Yes

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Do you need a contact lens exam(Required)

Yes

Primary Care Physician(Required)

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Allergies to medication?(Required)

Yes

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Yes

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Please hand us your medication list or otherwise please list them here :(Required)

HIPPA COMPLIANCE ACKNOWLDGEMENT OF RECEIPT

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of privacy practices. We protect your health information and what rights you have regarding it. If we need to disclose your health information outside of our office we will ask for your written permission. If you would like a copy of this policy please feel free to ask for one.

I acknowledge that I have reviewed this policy and that I was offered a copy of "Notice of Privacy Practices"

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PRECISION EYE CARE CANCELLATION POLICY

Precision Eye Care's goal is to provide patients with quality eye care in a timely manner. We have implemented a NO SHOW and CANCELLATION POLICY which enables us to better utilize available appointments for our patients in need of care. The following policy is with regard to patients who fail to keep their scheduled office appointments.

Patients who fail to show up to their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time, shall be subjected to a "NO SHOW/CANCELLATION FEE" of $50.00. Consideration will be given, at doctor's discretion, in the event of an actual emergency where prior notice could not be given.

Please be courteous and call Precision Eye Care of NJ promptly if you're unable to attend your appointment. This time will be relocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another patient the possibility to have access to a visit.

The fee associated with the cancellation policy is not covered by the insurance and is therefore the sole responsibility of the patient.

TO CANCEL or RESCHEDULE please call or text (732) 842-9177. If you have any problem getting through, you can always leave a message with your name, appointment date and cancellation reason or request for rescheduling.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. A photocopy of this consent shall be considered as valid as original.

PATIENT/ PATIENT REPRESENTATIVE SIGNATURE:

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If you're not the Patient, please identify your relationship to the patient.(Required)

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Annual Contact Lens Agreement Precision Eye Care of NJ

Contact lenses are medical devices that require additional testing to ensure safety and an accurate prescription. An annual contact lens evaluation is required every year for all contact lens wearers in order to prescribe contacts. The fee for this evaluation is separate froM the fee for the routine eye exam and is not refundable. Some vision plans do cover all or part of this fee, while others do no. Any amount not covered by your vision plan is due In full at the time of service.

Contact Lens Evaltiation Fee:
- New patient soft lens evaluation: Sphere: $150 Astigmatism/ Toric: $170 lyiultfocal Starts $195
- Established patient soft lens evalUation: Sao and up
- New Patient RCP/Hybrid evaluation: $250 and up (based on complexity)
- Established patient RGP/ilybrid evalusition: $170 and up

The exact fee within these ranges depends on the exact type of lens and complexity, and will be determined by your doctor. If you have questiont about the expected fee for your evaluation, you can discuss that with your doctor.

The contact lens evaluation fee includes:
1. All of the necessary measurements required to determine the right fit and prescription for you.
2. Any training necessary for the insertion and removal of your lenses up to 2 training, any additional training $45.
3. Any follow ups needed to finalize the prescription of your contact lenses, or to address issues you may be having with your lenses (up to 2 follow ups)
4. Trial pair (if neededfindicated).

The contact lens evaluation does not include your'annual supply of contact lenses, which can be ordered after the prescription has been finalized. It also does not include medical office visits for issues unrelated to the evaluation of your contact lenses, like dry eye, eye infection, injuries and ocular disease.

By signing this form, you are acknoMedging that:
- Contact lens evaluation fees are non-refundable and payment is due at time of service.
-Your prescription is valid for one year.
- Proper care of your lenses is expected. Failure to properly care for your lenses may result in numerous eye problems, such as corneal ulcers and potential loss of vision.

Bysigning this for I agree to my contact lens exam:

Patient Name(Required)

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