Polycarbonate Lens Policy

Polycarbonate Lens Policy
Your child’s eyes are very important to us. Your eye doctor has recommended polycarbonate lenses because they have anti-shattering properties and they are a lot stronger withholding breakage in case of any accident.

Regular lenses can break in small pieces that can injure the eyes.

If after all your answers and concerns were answered and you feel that polycarbonate lenses are not important to your child’s eye protection, we request that you sign this letter confirming that you understand the possible risks involved in not proceeding with polycarbonate lenses.

I would like to proceed without polycarbonate lenses.

I have read and understand the above conditions and I will comply with the accordance and contents.
Signature of Parent or Legal Representative*

Clear
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date*

MonthDayYear
If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.
Name of Legal Representative

First NameLast Name
Relationship to Patient
Should be Empty: