I'm generally not in favor of using many disclaimer forms for patients to sign, but sometimes they
can serve a good purpose. Sometimes called an Informed Consent, these written documents provide
important information to patients about services or products and they can prevent misunderstandings
about office policies. One of the criteria I use to determine if we should adopt a signature form is
the frequency of misunderstandings. I am mindful that patients generally dislike legal forms that
they are asked to sign and that too many of these can create a negative impression.
One event that has happened often enough in my practice is when a patient can't adapt to progressive
addition lenses, the job is remade into a flat-top bifocal, and the patient requests a refund of the
difference in the fees. Most wholesale labs will cover the cost of the second pair of lenses at no
charge, but the first pair is discarded and the cost for the progressive lenses remains. Our office
policy mirrors that lab policy: we remake Rxs that are not adapted to, but no refund is provided. With
the difference in my fees between progressives and flat tops at over $100, I feel this policy should be
explained in advance.
Here are a few points we have learned about progressive lens educational forms.
- We have a very high success rate with progressive lenses, so we only present the form to patients
who are ordering them for the first time. Once a patient has worn these lenses, they know what to
expect.
- Although we train our staff well to present the benefits of various lens options to patients, I
also believe we owe them a balanced explanation, which includes the drawbacks. The form ensures the
essentials of this are not forgotten.
- We often ask the patient to initial the form, rather than signing his full name. This gives us the
security that the form was read and agreed to, but it is a little less intimidating.
- We keep the original form in the patient's file. A copy is given to the patient only if requested.
Here is the form I developed for my practice. Feel free to adapt it to your needs as you see fit.
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PROGRESSIVE ADDITION LENSES
All progressive addition lenses (also called invisible or no-line multifocals) have a slight optical
distortion in the outer portions of the lens, which can make some objects appear bowed or curved, or can
cause a feeling of motion when the head is turned. The reading zone in progressive lenses is wide enough
for most purposes, but it may be narrower than some other bifocal styles. These factors are usually minor
and disappear with wear. The advantages of this lens generally outweigh the problems and the success rate
is over 95%. While most people are not bothered by these characteristics, some will find it unacceptable
even after a one-week adaptation period.
If you cannot adapt to progressive addition lenses, we will make new lenses in any other design that you
wish at no charge, within 30 days of dispensing. Since the original lenses were a custom prescription
item which must be discarded, there are no refunds of the difference in cost if the remake pair is of
lesser value.
I have read and understand this policy.
Patient's initials ________ Date _________ Technician ____________________
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