Name*

First Last

Phone*

Texas law requires that a follow up visit with the patient wearing the contact lenses be done preceding the initial contact lens evaluation. This visit is to insure good vision, comfort and that the contact lens is fitting the eye properly. This visit is usually performed at one (1) week.

I understand that I am responsible for the timely follow up with the doctor wearing my contact lenses to insure that the contact lenses are fitting my eyes properly. I also understand that my failure to do so may result in additional fees starting at $45 and that the doctor will not release my contact lens prescription without this visit.

Signature*

Date

Contact Lens Follow Up Acknowledgement

Urban Eyes Inc