Contact Lens and Glasses Prescription Signed Acknowledgement Form
Contact lenses are medical devices which require ongoing medical care for optimal performance and safety. Please contact our office if you experience any signs of complications including: pain, redness, loss of vision.
Name
First Name
Last Name
How would you like to receive your prescription?
*
Paper copy by mail
Electronic by email
If you opted to receive your prescription by email, please type it below
example@example.com
Please sign below indicating that you were provided with options to receive your contact lens prescription at the completion of your contact lens fitting.
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: