Applies to the examination of previously prescribed soft and rigid contact lenses and renews your
Soft Contact Lenses
Applies to patients being fit with soft contact lenses for the first time or current contact
lens wearers requiring a change into a different soft lens.
Applies to current patients changing between spherical and toric contact lenses.
Applies to current patients changing into daily contact lenses for the first time.
Rigid Gas Permeable Contact Lenses
Applies to patient’s first fitting with rigid gas permeable contact lenses or patients requiring a
change into a
different rigid material or design. RGP Lenses not included.
The above fitting fee includes:
Initial Fitting Appointment
Diagnostic Lenses Used (excludes RGP)
Care & Handling Instruction -- New Wearers
3 Contact Check Appointments
Patients have 3 months to follow up with their contact check appointment(s). After that, any additional
appointments may be subject to a new fitting charge. Due to the nature of custom contact fitting
services and time invested, refunds are not considered. Once contacts have been supplied or purchased,
there are no exchanges.
Contacts are to be paid in full at the time of service. The exception would be if your insurance covers any
part of the cost.
After the insurance portion has been paid, the remaining balance must be paid in full.
By signing below, I agree to the contact lens fitting fees that I have initialed above. I understand that if I
am using Medicare
or any other commercial medical insurance that does not cover this service, I will be responsible for these
Signature of Patient or Patient's Legal Representative
655 Medical Center Dr. NE
Salem, Oregon 97301
MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
CONTACT LENS WEARING PROCEDURE
Congratulations! You are taking your new contact lenses home today. We would like to remind you of a few things
that we discussed today at your appointment.
Always remember to wash your hands before handling your contact lenses.
Start your wearing time at 4–6 hours the first day and continue to 6-8 the second day. Remember to give
your eyes a rest
from contacts now and then. Weekends or evenings are a good time to wear your glasses and let the eyes
have full oxygen exposure.
Try not to over wear your contacts.
Cleaning your contacts nightly is important. Not only does it keep your eyes healthy, it lets you enjoy
comfortable lenses daily.
It also gives you the wearing time that was intended for your brand of contacts.
It is always a good idea to put lenses on after your face is clean. Any lotions, shaving cream or
makeup, should be done after
you put your lenses in. This will help to make sure no residue is left on your hands. Soft lenses will
absorb things like hair spray,
perfumes and lotions, to name a few.
Any time you notice a lens is damaged by a tear or a little piece is missing,
DO NOT WEAR IT. Throw it out and start with a fresh lens.
If a lens ever feels uncomfortable, scratchy or the eye(s) feel irritated remove the lens and check to
see if the lens is inside out.
Look for a chip or tear in the lens. If the lens is not damaged, try the lens on again. If it is still
uncomfortable, remove the lens
and leave it out. Call the office and schedule a contact check appointment with a lens specialist if
the eye(s) do not feel better.
Any time you have a concern or question, please call our office.
We are always glad to help you. 503–581-5287.
Remember, your prescription is valid for one (1) year.
By signing below, I have read and understand the contact lens wearing procedure listed above.