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Home » Eye Care Services » Private: Gentle Vision Shaping (no glasses, no surgery) » Gentle Vision Shaping System (GVSS)™ Agreement

Gentle Vision Shaping System (GVSS)™ Agreement

We anticipate a period of active care of about one month. The actual time of treatment is based on your ability to adapt to your vision retaining contact lenses and the flexibility of your cornea. Missing appointments interferes with your progress and will prolong treatment time. Following the period of active corrective changes, vision retaining contact lenses will be worn to ensure stability.

GVSS is charged as a total comprehensive fee. The fee is not dependent on the exact number of visits or vision retaining lenses used. Appointments will be made as often as necessary to accomplish our mutual goals of improving your vision. Lost, damaged or spare vision retaining lenses will be replaced for a charge of $150 Single Vision and $300 Multifocal for each eye. It takes about one week to replace a retainer.

If circumstances beyond your or our control prevent you from continuing or completing your treatment, there are certain fees that cannot be refunded. Each case will be determined individually based on the amount of office time and vision retaining lenses used up to that point. If the fee due exceeds the total of payments made, it is understood that you are responsible to pay the difference even though treatment has been discontinued. If the payments made exceed the fee for services, you will receive the appropriate refund.

The fee for the Gentle Vision Shaping System is between $2,280 and $2,580. There are three payment plans available.

1. You may pay the entire fee at the time the vision retainers are ordered. In such cases, a 10% discount will be applied making the new total $2,280.

2. You may pay the fee over three months after leaving an initial payment of $1,000. For each of the next three months your credit card will automatically be billed $500 each month. The total you will have paid will be $2,500.

3. You may pay $215 per month for the next 12 months. The total you will have paid will be $2,580. Your credit card number ________________ that expires on __/__ will automatically be billed each month.

I have read and understood the above and am in agreement with its’ contents. I am choosing payment plan number __________.

Patient’s Signature ___________________________________________________

Date _______________________________________