Policies, Consent, and Submit Data
INSURANCE AND FINANCIAL RESPONSIBILITY AGREEMENT
CONTACT LENS FITTING POLICY
I hereby authorize payment of vision insurance benefits to Laguna Coast Optometry and Duong Nguyen O.D.
Inc. for professional services and optical products rendered. I authorize the release of any medical information
necessary in order to process my insurance claims on my behalf. I understand that I am financially responsible
for all services and products rendered at the time of service, whether or not covered by my insurance. If any
co-pays and/or deductibles are required, I agree to pay them to Laguna Coast Optometry. Should there be any
disputes regarding my insurance or vision benefits, I will settle them on my own with my insurance or employer.
Contact lenses, including non-prescription color & cosmetic lenses,
are medical devices that require proper contact lens fitting, solution care, and replacement schedule.
Contact lens prescriptions are different than those of eyeglasses, and therefore would require a contact lens fitting.
Most contact lens fitting will include free diagnostic trials, except for custom contacts.
Proper contact lens care is patient's sole responsibility per doctor's instructions. Any deviation from proper
contact lens care, including over-wear or change in lens solution, can result in eye irritation, infection, or other complications.
Contact lens trials must be worn on all follow-up visits. We cannot dispense lost, torn, or misplaced trials without a follow-up
visit with the doctor. If patient continues to lose, tear, or misplace trials, s/he shall deem unfit for contact lens wear.
Contact lens fitting fees shall include an initial fitting plus 1 follow-up visit (at no additional charge). Any additional
follow-ups will incur additional office visit fees. All contact lens fitting & follow-up charges constitute professional fees (non-refundable),
whether patient decides to continue contact lens wear or not.
I understand and hereby consent to these contact lens policies - holding harmless Laguna Coast Optometry,
Duong Nguyen O.D. Inc., or its affiliated optometrist(s) for any contact lens problem, infection, and/or permanent loss of vision due to non-compliance.
Employs digitally enhanced camera to photograph the retina in order to better
monitor for eye diseases like glaucoma and macular degeneration. It has no side
effects similar to those of pupil dilation.
Serves the same purpose as retinal photography, except that light sensitivity and
blurry reading will be experienced for about 4-6 hours afterward.
Eye pressure Test
I have been informed of the need for an eye pressure test to check for glaucoma. I
understand that if I have glaucoma and an eye pressure test is not performed, the
disease may go undetected resulting in possible loss of vision.
I understand that I will be responsible for any copay(s) associated with these procedures per
my specific insurance plan. I approve for any or all procedures mentioned above as recommended
by the Doctor - otherwise please check below to decline: