Northland Eye Specialists

Consent Form for
Delivery of Prescription

This prescription is for *
I would like my prescription sent to me electronically via *
Signed Acknowledgement Form for Prescription Release
Patient/Legal Guardian Name *

Sign below to acknowledge that you were provided with a copy of your eye glasses/contact lenses prescription after completing a refractive eye examination.
Signature of Patient or Legal Guardian *Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

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