We are happy to loan =
this
contact lens to you while you are waiting for your replacement contact len=
s to
arrive. We must caution you, however, that this contact lens was not made
exactly according to your specifications. For example, the oxygen transmis=
sibility
of this loaner contact lens may be different from your own. Therefore, it should be worn on a li=
mited
and temporary basis only.
Please watch your eye
closely for any adverse effects, such as increased redness or injection of=
the
eye, swelling, blurring or fogging of
vision, burning, increased light sensitivity, pain or unusual irritation, =
long
lasting blur through your glasses after removing your loaner contact lens
(called "spectacle blur"). If any of these signs or symptoms
The service fee for t=
his
Contact Lens Loaner Program is $ 5.00 -.
ASSUMING it is returned in good condition. If it is not returned in good
condition, an additional $20.00 will be charged.
Patient Agreement:
I have read the Conta=
ct Lens
Loaner Agreement. I acknowle=
dge and
accept the risk(s) of wearing a contact lens that was not specifically des=
igned
for my eye. I agree to call Dr. Cowley's office
immediately if any problems arise.
_______________________________________________ =
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