Patient History Form

A contact lens fitting is a professional service separate from the routine vision exam. The fitting includes the trial lenses and any follow-up appointments to provide you with a contact lens prescription. By signing below, you acknowledge that you will pay for the contact lens fitting at the time of the service.

I acknowledge that a copy of Dunlap Vision's Notice of Privacy Practices were made available to me. If using insurance to cover any of my charges I agree to pay any deductibles, copays or non-covered services.