Can the Ortho-K Agreement be signed electronically?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and durable record retention are satisfied.

Who can sign for a minor patient?

A parent or legal guardian with authority should sign. Document guardian relationship and contact details; consider additional identity verification for remote signings.

Is notarization required for clinical consent?

Not typically required for routine medical consent. Some states or specific legal situations may request notarization or witnesses; confirm state requirements beforehand.

How should signed agreements be stored?

Store signed PDFs and audit trails in an encrypted, access-controlled repository. For HIPAA-covered entities, retain records per 45 CFR §164.530(j).

What if a patient revokes consent?

Document revocations in writing. Explain effects of revocation on ongoing treatment and retain the revocation notice in the clinical record.

How to handle missing or incorrect fields?

Do not proceed until essential fields are corrected. Amendments should be initialed and dated by signer or executed as a new agreement to avoid disputes.

Electronic Signature
Templates
Healthcare
Healthcare Ortho-K Agreement

Healthcare Ortho-K Agreement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE ORTHO-K AGREEMENT

Patient Information

Patient Name

Date of Birth

Gender

Phone

Address Email

Emergency Contact

Contact Name

Relationship

Phone

Insurance Information

Insurance Provider

Policy Number

Group Number

Subscriber Name

Medical History

Current Medications Allergies Prior Ocular Surgeries or Procedures Chronic Conditions Contact Lens History

Proposed Ortho-K Treatment

The proposed treatment is orthokeratology (Ortho-K) lens fitting intended to temporarily reshape the cornea to reduce refractive error for daytime unaided vision. Proposed lens type:

Anticipated treatment plan includes diagnostic fitting, baseline topography and refraction, overnight lens wear with scheduled follow-up visits. Initial fitting date (if scheduled):

Risks, Benefits, and Limitations

I acknowledge that the clinician has explained the nature and purpose of Ortho-K treatment. Benefits may include reduced dependence on daytime refractive correction. Risks include, but are not limited to, microbial keratitis (corneal infection), corneal abrasion, corneal staining, reduced best-corrected acuity, fluctuating vision, glare and halos, allergic reactions, lens intolerance, neovascularization, and the potential need to discontinue treatment. There is no guarantee of complete correction or permanence.

I understand that compliance with insertion, removal, cleaning, and wearing schedules is critical to safety and efficacy. Failure to follow care instructions increases the likelihood of complications.

I have read, understood, and had the opportunity to ask questions about the risks and benefits described above.

Alternatives

Reasonable alternatives to Ortho-K include spectacle correction, daytime soft contact lenses, gas-permeable daytime lenses, observation without intervention, and refractive laser surgery where appropriate. I have been informed of alternatives and their relative risks and benefits.

I have considered alternatives and request to proceed with Ortho-K fitting.

Post-Fitting Care, Follow-up, and Emergencies

Follow-up appointments are required as part of the protocol. Typical schedule: next-day check, 1-week, 1-month, 3-month, and as clinically indicated. I understand I must return for scheduled visits and contact the clinic immediately for pain, significant vision change, redness, discharge, or other concerning symptoms.

Preferred follow-up clinic contact (clinic name or provider)

Financial Responsibility

I understand that charges for professional services, lens fabrication, and supplies may apply. Insurance coverage varies and is not guaranteed. I am responsible for payments not covered by insurance, including replacement lenses, lost/damaged lenses, and fees for missed appointments.

Initial fitting fee Acknowledgment of financial responsibility I accept financial responsibility for services and materials not paid by insurance.

HIPAA / Privacy Authorization

I authorize the use and disclosure of my protected health information for treatment, payment, and health care operations as necessary for the provision of Ortho-K services. I understand my rights to privacy and that a separate full Notice of Privacy Practices is available. I authorize release of relevant records to other treating providers as required for continuity of care.

I acknowledge receipt of the privacy practices and authorize disclosure as described above.

Authorization Duration & Withdrawal

This authorization remains in effect until revoked in writing or until the following expiration date:

I understand I may withdraw this authorization at any time by giving written notice to the provider, but withdrawal will not affect disclosures or actions taken in reliance on this authorization prior to receipt of the written withdrawal.

Consent and Acknowledgement

By signing below I certify that I have read and fully understand this Ortho-K Agreement. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction. I consent to the proposed Ortho-K treatment and associated diagnostic and follow-up care. I understand that I may discontinue treatment at any time.

I voluntarily consent to Ortho-K treatment and related care.

Additional Notes

Guardian / Minor

Patient is a minor; parent/guardian is signing on behalf of the patient.

Printed Name:

Signature:

Date:

Relationship to Patient (if signing for minor):

Witness Name (optional):

What a Healthcare Ortho-K Agreement Covers

A Healthcare Ortho-K Agreement is a clinical consent and service contract used when fitting orthokeratology lenses to temporarily reshape the cornea for myopia control or refractive correction. The agreement documents patient eligibility, medical history, treatment description, expected outcomes, risks and contraindications, follow-up schedule, care instructions, fees, refund or warranty terms, and signature blocks for the patient or authorized guardian. It also records HIPAA-related acknowledgements for protected health information and any authorizations for sharing clinical records with third parties.

Why a Clear Ortho-K Agreement Matters

A formal Ortho-K Agreement clarifies clinical expectations, documents informed consent, reduces legal ambiguity, and creates an auditable record for both patient care and compliance with health privacy rules such as HIPAA. Proper documentation supports clinical continuity and risk management.

Who typically completes and signs this agreement

The Ortho-K Agreement is completed by clinical staff and signed by an authorized patient or guardian prior to lens fitting and treatment initiation.

Optometrists and ophthalmologists who evaluate and prescribe orthokeratology lens treatment and record clinical findings and contraindications.
Clinic administrators or intake staff who prepare the form, verify insurance or payment arrangements, and capture demographic and contact data.
Patients and parents/guardians who review risks, confirm medical history, consent to treatment, and commit to follow-up care and lens handling requirements.

Accurate completion involves the clinician, administrative staff, and the patient or parent/guardian to ensure medical, legal, and billing items are recorded.

Core elements to include in a professional Ortho-K Agreement

A complete agreement combines clinical, legal, and administrative content so all parties understand obligations, risks, timelines, and financial terms.

Patient identification

Full legal name, date of birth, contact details, government-issued ID where relevant, and guardian information for minors to ensure correct patient matching and legal authority.

Clinical eligibility

Summary of refractive error, corneal measurements, relevant ocular or systemic conditions, and clinician determination that the patient is an appropriate Ortho-K candidate.

Treatment description

Purpose of Ortho-K, expected short-term and long-term outcomes, typical duration of nightly wear, and statements that results can vary and are not guaranteed.

Risks and contraindications

Detailed disclosures of risks (infection, corneal staining, visual fluctuations), contraindications, signs of complication, and required immediate actions if problems occur.

Care, follow-up, and compliance

Lens care instructions, wear schedule, required follow-up visits (first-night check, 1-week, monthly reviews), and patient responsibilities for reporting issues promptly.

Fees, refunds, and warranty

Itemized fees, payment terms, refund or replacement policy for lenses, and any warranty or service limitations tied to noncompliance or lost/damaged lenses.

Stepwise process to complete and execute the agreement

Follow these steps to prepare, review, obtain consent, and store the signed Ortho-K Agreement.

01

Collect patient data: Assemble ID, medical history, and contact information before the visit.
02

Explain treatment: Review benefits, risks, alternatives, and expected follow-up with patient or guardian.
03

Document consent: Fill form fields, obtain signatures, and record signer authentication details.
04

Store securely: Save the signed agreement in the patient chart and secure electronic repository.

How to configure an online Ortho-K workflow

Key settings for an electronic completion workflow that meet clinical, privacy, and operational needs.

Field	Configuration
Document Template	Use a clinic-approved template with pre-placed required fields and conditional consent sections.
Authentication	Require signer email plus optional SMS code or clinic identity verification for minors.
Notifications	Automate reminders 48 and 24 hours before appointments and follow-ups.
Storage	Store signed PDFs in an encrypted, access-controlled EMR or document repository.

Technical requirements for digital completion and storage

Ensure your e-signature platform and clinic systems meet file, security, and integration needs for patient records.

File formats: PDF and DOCX support for templates and signed output.
Integrations: Connector options for EMR/CRM systems like Salesforce, NetSuite, Google Workspace, Box, and Procore.
Security basics: TLS 1.2/1.3 in transit and AES-256 at rest; HIPAA BAA available where required.

Typical e-signing flow for an Ortho-K Agreement

A straightforward electronic workflow reduces handling errors and creates an auditable signature trail for clinical records.

Upload document: Clinic uploads the Ortho-K template and pre-fills known patient fields.
Add signers: Designate patient and guardian signer roles and contact emails or phone numbers.
Authenticate signer: Select email link, SMS code, or stronger identity proofing as needed.
Capture and store: Signed PDF and audit trail are saved to the secure clinical repository.

Common clinical timelines and follow-up windows

Ortho-K care requires scheduled checks; document these dates clearly in the agreement so both clinic and patient meet obligations.

Pre-treatment evaluation:

Complete corneal mapping and baseline tests before initiating lens wear.

Lens fitting appointment:

Schedule the lens fitting and instruct on first-night wear procedures.

First-night check:

Arrange evaluation the morning after first wear to verify fit and vision.

One-week follow-up:

Assess corneal response, adjust lenses, and confirm care adherence.

Ongoing reviews:

Establish monthly-to-semiannual checks to monitor corneal health and refractive stability.

Common preparation and execution pitfalls to avoid

Incomplete medical history entries that omit systemic medications or allergies leading to inappropriate fittings or adverse events.
Using ambiguous language for refund or warranty policies that creates disputes when lenses are lost or damaged by noncompliance.
Failing to obtain documented guardian consent for minors before dispensing lenses or sending lenses home.
Transmitting signed forms via unsecured email without encryption, exposing PHI and risking HIPAA violations.

Legal and clinical risks from incomplete or incorrect agreements

Invalid consent: May expose clinic to malpractice claims.

HIPAA violation: Civil fines and corrective action (45 CFR §164.530(j)).

Improper fitting: Increased risk of infection or corneal damage.

Missing authorization: Limits ability to share records with other providers.

Documentation gaps: Compromise defense in litigation or regulatory review.

Fraud exposure: False signatures or unauthorized payor billing risks.

eSignature vendor comparison for signing and storing Ortho-K Agreements

Comparison of common vendor pricing and capabilities relevant to healthcare consent forms; signNow is listed first in the header per platform comparisons.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA available)	Yes	Yes	No	No

FAQs — common questions about Ortho-K Agreements and e-signing

Answers to frequent questions about consent, signatures for minors, e-signature legality, and secure storage.

Need help? Contact support

Can the Ortho-K Agreement be signed electronically?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, provided intent, consent, attribution, and durable record retention are satisfied.
Who can sign for a minor patient?
A parent or legal guardian with authority should sign. Document guardian relationship and contact details; consider additional identity verification for remote signings.
Is notarization required for clinical consent?
Not typically required for routine medical consent. Some states or specific legal situations may request notarization or witnesses; confirm state requirements beforehand.
How should signed agreements be stored?
Store signed PDFs and audit trails in an encrypted, access-controlled repository. For HIPAA-covered entities, retain records per 45 CFR §164.530(j).
What if a patient revokes consent?
Document revocations in writing. Explain effects of revocation on ongoing treatment and retain the revocation notice in the clinical record.
How to handle missing or incorrect fields?
Do not proceed until essential fields are corrected. Amendments should be initialed and dated by signer or executed as a new agreement to avoid disputes.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now