Contact Lens Insertion and Removal Checklist
Complete this checklist to ensure safe and proper handling of your contact lenses.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Checklist Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you worn contact lenses before?
*
Yes
No
Contact Lens Handling: Please indicate if you have completed each step below.
*
Rows
Completed
Not Applicable
Washed hands thoroughly with soap and water
1
2
Dried hands with a lint-free towel
3
4
Checked lens for damage or debris
5
6
Verified lens orientation (not inside out)
7
8
Placed lens on fingertip
9
10
Contact Lens Insertion Steps: Please indicate if you have completed each step below.
*
Rows
Completed
Not Applicable
Held upper eyelid to prevent blinking
11
12
Pulled down lower eyelid
13
14
Placed lens gently on the eye
15
16
Released eyelids slowly
17
18
Blinked to position the lens
19
20
Contact Lens Removal Steps: Please indicate if you have completed each step below.
*
Rows
Completed
Not Applicable
Washed hands before removal
21
22
Looked upward and pulled down lower eyelid
23
24
Pinched lens gently with thumb and index finger
25
26
Removed lens from the eye
27
28
Placed lens in case with fresh solution
29
30
How comfortable are your lenses after insertion?
*
Very Uncomfortable
1
2
3
4
Very Comfortable
5
1 is Very Uncomfortable, 5 is Very Comfortable
Did you experience any of the following issues?
*
Redness
Irritation
Blurry vision
Excessive tearing
None of the above
Other
Additional comments or concerns (optional)
Submit Checklist
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