PATIENT NAME________________________________________ DOB_____________________ Your atropine program is 12 months in length and is $249.00* for the initiation of treatment. $249.00* will also be due at each follow up appointment 3 months, 6 months and 9 months. Your Atropine Therapy Program includes the following: Testing related to monitoring progression of myopia (i.e., refraction, corneal topography, axial length measurement, and office visit) The program does NOT include: Atropine drops. The drops will be diluted from full strength by a licensed compounding pharmacy that will fill the prescription and dispense the drops directly to you.** OSRX 1120 Kensington Ave. Suite E Missoula, MT 59801 1-855-466-1076 A comprehensive eye exam. This must be current within 1 year to be eligible for the program. This program outline is true and correct until ____________________; after this time, the data collected becomes outdated and additional consultation is needed. All additional consultations carry a fee of $249.* I have read and understand the above and had the opportunity to ask questions. _______________________________________ ______________ Patient Signature (parent if under 18) Date *Fees are subject to change at our discretion **Fees, and dispense / storage instructions are subject to change at the discretion of OSRX.