Consent Form for
Delivery of Prescription
This prescription is for
*
Eyeglasses
Contact Lenses
Both
I would like my prescription sent to me electronically via
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Email
Fax
Signed Acknowledgement Form for Prescription Release
Patient/Legal Guardian Name
*
Date of Birth
*
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.
Date Signed
*