Myopia Care Orthokeratology (Ortho-K) program for your child will be 12 months in length and the fee will be as noted above. This is a one-time fee. During this time, our specialty lens team will work together to provide your child with the most customized care for their myopia management needs.

Patient Name:

Date:

Parent Email:

Parent Name:

Practice Name:

Doctor:

24-Month Fee:

Annual Myopia Care Maintenance Program Fee Year 3 and beyond:

The First 24 Month Program Fee Includes the Following:

Looking Ahead:

Lens Replacement Fees:

Guarantee:

Patient Name (Parent or Guardian if under 18):*

Age of Patient:*

Date:*

Patient (Parent or Guardian if under 18):* Get a better browser, bro.