Contact Lens Form

It is our mission to provide the best quality eye care and eyewear for our patients. Every pair of eyeglasses ordered from Total Vision Family Eye Care is custom made to order. Therefore, we cannot refund any products that are not resalable or returnable to the manufacturer. We are happy to service all our products and guarantee their quality and workmanship with a one-year manufacturer warranty for frame and lenses. This warranty ensures any damages are repaired at no cost to you one time within the year.

Total Vision Family Eye Care will honor a one-time prescription change made by the doctor up to 60 days following the original order. Subsequent changes will incur additional charges. If a patient does not adapt to a pair of prescription progressive eyeglasses within 60 days, Total Vision Family Eye Care will remake the glasses (one time) into a standard bifocal or single vision lenses at no additional charge to the patient. NO REFUND WILL BE GIVEN FOR THE PRICE DIFFERENCE IN MATERIALS. The order was custom tailored to you and cannot be returned to the manufacturer.

CONTACT LENS EVALUATION/MANAGEMENT FEE:
Evaluation/Management fees start at $99 and may increase depending on each patient’s prescription and needs. Your insurance may offer a discount or copay to offset some of these costs. Your examination results will determine which type of contact lens is best for your needs.

If needed, up to two follow-up visits are included within the first 30 days. Any additional follow-up visits will incur a $40 per visit charge. We will take back unopened boxes of contacts if there is a change in your prescription at your next checkup and apply a credit toward your next contact lens purchase. FINANCIAL POLICIES:

1. All insurance co-payments are paid at the time of service.
2. If we are not a network provider with your insurance, the patient is expected to pay all expenses at the time of services and/or materials upon completion. It is the patient’s responsibility to submit charges to the insurance company for reimbursement.
3. All orders are custom, and therefore are to be paid in full at the time of the order unless prior arrangements are made. There are no refunds on any orders or unclaimed materials.
4. If unpaid services/materials need to be placed for collection, the patient will be responsible for the cost of all reasonable attorney fees and/or other collection fees.