Myopia Care Program
Ortho-K 1-Year Agreement

Ortho-K 1-Year Agreement

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  • ’s Myopia Care Orthokeratology (Ortho-K) program will be 12 months in length and is
  • This is a one-time fee. During this time, our specialty lens team will work together to provide
  • with the most customized care for their myopia management needs
  • The First Year Program Fee Includes the Following:

    • Initial fitting and evaluation of custom lenses
    • ALL lens changes made by the doctor within the first 12 months
    • Unlimited follow-ups; typically includes approximately 6-8 visits
    • Final pair of lenses, plus a spare pair of lenses, if no lenses were lost or broken
    • ALL topography, ultrasound and vision testing
    • ALL training on insertion and removal of lenses
    • 24/7 communications necessary between parent/patient and staff/Doctor
    • Behavioral coaching through emails/messages that help parent & patient implement natural behavioral changes needed to support myopia management at home
  • Looking Ahead: Year 2 and beyond: We offer a Myopia Care Maintenance Program which includes:

    • ALL Myopia Care follow up appointments
    • ALL topography, ultrasound and vision testing as needed
    • A comprehensive eye exam
    • Any additional training & learning
    • Behavioral coaching messages to support natural changes of behavior in the home
  • is maintenance program fee, for 12 months.
  • fee will be, If you exceed the 12-month period. This does NOT include a new pair of lenses if the lenses need to be replaced. Any medical care during this period will be treated separately and your medical insurance rules will apply.
  • Ortho-K lens replacements range from $250-$350 per lens, depending on the lens design chosen to best meet the needs of
  • If rare circumstances prevent you from continuing your treatment during the first three months of care, we will gladly refund all fees paid, less
  • Program Requirements:

    • Be on time. Arriving late will create the need for your appointment to be rescheduled.
    • When you need to cancel or reschedule an appointment, inform us at least 48 hours before the appointment. A fee will be imposed if insufficient time is given.
    • Do the homework and preparation that is needed for maximum success for the program including viewing training videos and reading materials

    This program outline is true until

  • after this time, The examination data collected becomes outdated and an additional consultation is needed
  • All additional consultations carry the same fee as the consultation fee
  • I have read, understand and agree to the terms noted above.

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  • Orthokeratology (Ortho-K)


  • Orthokeratology

    You are being fit with rigid gas permeable (RGP) contact lenses, also known as Ortho-K, refers to the use of specially designed RGP contact lenses to temporarily reshape the cornea (the clear layer on the front of the eye), allowing you to see clearly without the use of glasses or contact lenses during waking hours. The Ortho-K contact lenses must be worn on a regular basis during sleep in order to reduce the need for glasses or contact lenses during the day.

  • Complications and Side Effects

    Corneal Reshaping Treatment carries the same risks as other types of contact lenses, such as swelling of the cornea, scratching of the eye, irritation, infection, unusual eye discharge, excessive tearing, dry eyes, sensitivity to light, pain, redness, and distorted vision. These risks are usually temporary if the contact lenses are removed promptly and if appropriate professional care is received. In some instances, permanent corneal scarring, infection or blood vessel growth on the cornea may occur, which can lead to reduced sight in rare cases. Although uncommon, infection of the cornea can develop rapidly and lead to loss of vision. The risk of infection of the cornea has been shown to be greater among patients who wear their lenses overnight than among those who do not sleep in their lenses.

    I have read and fully understand the above information. I agree to adhere to the wearing and follow-up schedules as prescribed. If I fail to return for my scheduled follow-up visits, I may forfeit my chance to continue overnight wear of Ortho-K contact lenses. All of my questions concerning my eyes and contact lenses have been answered to my satisfaction.

  • (Parent to sign if patient is under 18 years of age)
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  • Orthokeratology (Ortho-K)

    My Commitment to My Lenses

  • Orthokeratology (Ortho-K)

    I am being fit with rigid gas permeable (RGP) contact lenses also known as Orthokeratology (Ortho-K). These contact lenses reshape the cornea (the clear layer on the front of the eye) for a short time, which allows me to see clearly without the use of glasses or contact lenses while I am awake.

    The Ortho-K contact lenses must be worn on a regular basis during sleep so that I can see clearly during the day without glasses or contact lenses.

    It is important that I agree to the following guidelines to keep my eyes healthy and allow me to wear contact lenses. Place a checkmark in each line to agree.

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