Contact Lens No Follow up Exam (Sample Letter)

LETTER TO A PATIENT EXAMINED AND/OR FITTED FOR CONTACT LENSES BUT WHO HAS NOT HAD MEDICALLY NECESSARY FOLLOW-UP EXAMINATION

(Physician’s Letterhead)

(date)

Dear   (Patient):

You have requested a copy of your contact lens prescription based on an initial examination [and/or] contact lens fitting. [Or We have received a request from _____ for a copy of – or a request to verify – your prescription for contact lenses.] It is important that you understand the differences between a spectacle prescription and contact lens prescription. It is usually possible to arrive at a valid eyeglass prescription at the completion of the initial eye examination. However, the initial eye examination does not include the additional testing and diagnostic lens fitting evaluation necessary to determine an appropriate contact lens prescription. Follow-up exams are necessary because lens design modifications may be needed before I can arrive at a final contact lens prescription.

In addition, there are eye conditions that may keep you from wearing contact lenses. These conditions may only be discovered during follow-up exams. Some of the conditions that might keep you from wearing contact lenses are: frequent eye infections; severe allergies; and dry eye (improper tear film). An ophthalmologist is the physician specialist who can diagnose and treat conditions that may prevent optimal contact lens wear.

There are also certain environmental conditions or personal practices revealed during follow-up exams that may prevent you from wearing contact lenses, such as: a work environment that is very dusty or dirty or your improper handling and care of the lenses. An important aspect of contact lens wear is learning how to properly wear the lenses and how to disinfect and clean them. Even if you have worn contact lenses before, I believe it is important for my office to evaluate or reevaluate your proper handling and care of the lenses. We can also advise you regarding the use of appropriate cosmetics. Improper use of cosmetics can lead to eye irritation as well as infection.

For the health of your eyes, I am unable to provide you with a prescription for contact lenses at this time. [Or … I am unable to provide ______ a copy of – or a verification of – your prescription for contact lenses.] After we have completed your medically necessary follow-up examination, however, I would be happy to provide you with your contact lens prescription.

Sincerely,

                                                                        , M.D.

Contact Lens Prescription Copy Request (Sample Letter)

LETTER TO A PATIENT EXAMINED AND FITTED FOR CONTACT LENSES WHO HAS REQUESTED A COPY OF THE PRESCRIPTION

(Physician’s Letterhead)

(date)

Dear   (Patient):

In compliance with the Fairness to Contact Lens Consumers Act, I am providing you with a copy of your contact lens prescription [Or I am providing a copy of – or verifying – your prescription for contact lenses to ____________.] Your prescription for contact lenses is based on an initial examination and contact lens fitting [and follow-up examination, if applicable]. It is important that you understand that continued follow-up exams are necessary to your eye health. Lens design modifications may be needed and it may be necessary to change your prescription.

In addition, there are eye conditions that may keep you from wearing contact lenses. These conditions may only be discovered during follow-up exams. Some of the conditions that might keep you from wearing contact lenses are: frequent eye infections; severe allergies; and dry eye (improper tear film). An ophthalmologist is the physician specialist who can diagnose and treat conditions that may prevent optimal contact lens wear.

There are also certain environmental conditions or personal practices revealed during follow-up exams that may prevent you from wearing contact lenses, such as: a work environment that is very dusty or dirty or your improper handling and care of the lenses. An important aspect of contact lens wear is learning how to properly wear the lenses and how to disinfect and clean them. Even if you have worn contact lenses before, I believe it is important for my office to evaluate or reevaluate your proper handling and care of the lenses. We can also advise you regarding the use of appropriate cosmetics. Improper use of cosmetics can lead to eye irritation as well as infection.

Please contact my office if you would like to schedule a follow-up appointment. The health of your eyes is our main concern and should be yours.

Sincerely,

                                                                        , M.D.

General Anesthesia

INFORMATION REGARDING GENERAL ANESTHESIA

I    (the patient, or person authorized to sign for the patient)     have been informed that the proposed surgery will be performed under general anesthesia. Although my doctor will not be administering the general anesthesia himself, he has told me that it will be administered by a qualified and licensed individual. I have been made aware of the need for this type of anesthesia and have been informed by my doctor of the following facts about general anesthesia: 

• General anesthesia produces an unconscious state; the whole body is affected. This type of anesthesia is produced by injecting drugs into the patient’s blood stream and by having the patient inhale other drugs (anesthetic gas).
• Frequently, the person who administers the anesthetic places a tube through the mouth or nose of the patient into the trachea (windpipe) to aid in managing the patient’s breathing (oxygen needs) and amount of the anesthetic gas. Occasionally, on recovering from general anesthesia, the patient will note soreness and pain in the mouth and throat areas from abrasions. If it is necessary to place a tube through the nose, nosebleeds may occur.
• Although very rare, strokes, brain damage, heart attacks and pneumonia are known complications of general anesthesia. All types of anesthesia involve some risk. Complications from all forms of anesthesia are rare, but may occur. There is a very remote possibility of death as a complication of general anesthesia.
• Other known complications of general anesthesia include (but are not limited to) broken teeth, allergic reactions, infection, liver failure, kidney damage, bleeding, blood clots, loss of limb function and paralysis.
• General anesthesia complications occur rarely. They can happen, unpredictably, regardless of the experience, care and skill of the anesthesia provider.

X                                                                                             X                                            

Patient (or person authorized to sign for patient)           Date

[Document in the patient’s chart that he/she received information regarding general anesthesia.]

Patient Has Terminated Relationship (Sample Letter)

DELIVERY CONFIRMATION

(Date)

Dear (Patient):

You have informed our office on (date) (by phone/letter/during your office visit) that you no longer wish to receive care from us.

Continued care is essential to the health of your eyes. You have an eye condition which will worsen without proper care (If the patient has a condition that requires specific care, state the care AND the consequences of  no care in clear, patient-friendly language.  If the patient has a condition that needs regular follow-up, state the frequency and urgency of the follow-up, AND state the consequences of not getting the follow-up at the recommended time in clear, patient-friendly language.)  Permanent damage may occur, resulting in visual loss or blindness. Kindly realize this letter is not meant to alarm you. We only wish to inform you of the seriousness of your condition, which we explained during office visits, and encourage you to seek proper care.

We will transfer a copy of your medical records to your new physician upon receipt of a signed authorization to do so.  An authorization form is enclosed for your convenience.

With best regards,

(Physician’s Signature & Name)

Noncompliant Patient (Sample Letter)

Sample Letter:  Noncompliant Patient (Gives Patient One Last Chance)

(Date)

Dear (Patient):

You have canceled your follow-up appointment on (date) without rescheduling. We have tried multiple times to reschedule your missed appointment. To date, you have not responded to our efforts. It is our understanding that you may have terminated your care with our office. 

Continued care is essential to the health of your eyes. You have an eye condition which will worsen without proper care (If the patient has a condition that requires specific care, state the care AND the consequences of  no care in clear, patient-friendly language.  If the patient has a condition that needs regular follow-up, state the frequency and urgency of the follow-up, AND state the consequences of not getting the follow-up at the recommended time in clear, patient-friendly language.)  Permanent damage may occur, resulting in visual loss or blindness. Kindly realize this letter is not meant to alarm you. We only wish to inform you of the seriousness of your condition, which we explained during office visits, and encourage you to seek proper care.

If we have not heard from you within three weeks, we will assume that you have transferred your care to another physician and have terminated your relationship with this office. We will transfer a copy of your medical records to your new physician upon receipt of a signed authorization to do so.  An authorization form is enclosed for your convenience.

With best regards, 

(Physician’s Signature & Name)