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Office Policy Form

Contact Lens Evaluation/Fitting/Follow Up (if applicable)

The contact lens evaluation/fitting is a separate part of an eye exam. All contact lens patients need an evaluation annually to continue wearing or purchasing contact lenses. The evaluation/fitting is not covered by health care coverage except when medically necessary. Routine vision plans however, may have an allowance for the evaluation/fitting as part of the contact lens benefit. The fee for this service is based on lens type and any additional testing that may be necessary.

All contact lens fittings come with a 30 day re-check if needed. If you purchase contact lenses from our office, you will receive an additional 30 days for a re-check, if needed. If you schedule a follow up appointment outside of the allotted times, you will be charged for your visit. This visit will not be covered by your insurance.

Contact Lens Return/Exchange Policy (if applicable)

Disposable or frequent-replacement contact lenses may be returned only if the boxes have not been opened or written on and will only receive office credit. Diagnostic/ trial lenses are available for most disposable or frequent replacement lenses. These lenses may be provided free of charge to you for the purpose of making sure the lenses meet your satisfaction before ordering boxes. Should there be any questions or problems with the diagnostic/trial lenses; they should be addressed before opening or writing on the purchased boxes.

Gas permeable contact lenses can be returned or exchanged within 90 days from the initial visit. This 90 day trial period is designed for the purpose of making sure the lenses meet your satisfaction. Should there be any questions or problems with the lenses, they should be addressed within the 90 day trial period for office credit only. Please note that there will be no refunds or exchanges after the 90 day trial period.

Glasses/Lenses Exchange Policy/Customer Own Frame Use (if applicable)

All new glasses have a 90 day exchange period from the date of delivery. If glasses are exchanged within this period, Georgia Vision Center will remake the lenses at no additional charge, provided the frame is undamaged and in like new condition. Additional charges will be incurred if the replacement glasses are an upgrade to the original glasses purchased. Any returns due to a manufacturing defect will be covered under a one year, one time warranty unless specified otherwise.

Customers own frames are used at their risk. We will use extreme care with the frames, however, until we begin inserting lenses we do not know their durability. Should a customer's frame break, it will be the customer's responsibility to purchase or provide a new frame. There are no refunds given under this policy.

I have read and understand all of the above policies. I authorize Dr. Joey Arencibia, OD, his associates and technical assistants to provide diagnostic evaluation and treatment.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.