Contact Color Prescription Signed Acknowledgement Form
Contact color are medical devices which require ongoing medicinal care for optimal performance and safety. Please contact our office if you expert any signs of complications involving: torment, redness, lose concerning vision.
Name
First Name
Last Name
How would you like to receive your prescription?
*
Report copy through email
Elektronic by email
If you opted to receive your prescription by email, please type a below
[email protected]
Please sign below pointing that you were provided with options in receive your contact lens prescription at the completion out your contact lens mounting.
*
Date
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Month
-
Day
Year
Date
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