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Medical History

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Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Family Eye History

Does anyone in your family have any of these eye conditions?



Review Of Systems

Social History

Policies, Consent, Submit Data



Notice of Privacy Practices

Click Here - Important GVC Policies and Practices!







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Contact Lens Fitting and Evaluation Agreement



If you are a current contact lens wearer, or are interested in wearing contact lenses, you will need a contact lens evaluation.

The fees for the contact lens evaluation (exam) are as follows:

*Spherical Fit $65 *Toric Fit $90 *Monovision/Multifocal Fit $116 *Specialty Fit $116 and up

The contact lens evaluation (fit) fee is not included in the fee for your eye exam and is usually not covered by your insurance. The fee for your contact lens evaluation includes the initial visit and visits directly related to contact lens wear within a 90 DAY PERIOD. The fee also includes contact lens training class for new wearers. The fee is due in full at time of the fitting evaluation and is not a refundable service rendered.

The doctor will examine the health of your eyes annually to ensure that you are a proper candidate for contact lenses.

You are responsible for scheduling and attending your follow up visit to finalize your prescription. Without a finalized prescription, you will not be able to order contacts.

By signing below, you are acknowledging that you have read and understood our contact lens policy and agree that you will pay in full at time of service.



IWellness Exam



In an effort to provide a more thorough eye examination Georgetown Vision Center has incorporated the i-Wellness Exam, which includes the SD-OCT scan and Retinal Imaging as part of our comprehensive eye exam.

Like an MRI of the eye, but taking only seconds to perform, the SD-OCT provides high definition cross sections of your retina and optic nerve which can reveal signs of disease in exquisite detail that are invisible to traditional examination methods. Retinal Imaging captures comprehensive digital images of the surface of the retina.

We strongly recommend this procedure as part of your exam

The charge for the i-Wellness Scans is $35 in addition to the normal exam fees. Although not typically covered by insurance, it is an eligible expense with Flexible Spending Accounts.