CONSENT FORM FOR DELIVERY OF PRESCRIPTION

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I would like my eyeglasses prescription sent to me electronically via: *

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Signed Acknowledgement Form for Prescription Release

Acknowledgement Text

Sign below to acknowledge that you were provided with a copy of your eye glasses prescription after completing a refractive eye examination.

Patient/Legal Guardian Name: *

Date of Birth *

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Year

Patient/Legal Guardian Signature: *

Please type your name as a signature

Patient ID#:

Date *

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Year