Glasses Order Policy

Glasses Order Policy
1. You have an option to pay for the entire balance upfront to expedite the work. You will be reimbursed once we receive payment from your insurance.
2. A copy of your glasses prescription will be provided to you should you decide to order your glasses elsewhere.
3. All prescription lenses are custom-made and therefore cannot be returned once completed. Frames cannot be exchanged or returned after the lenses have been made.
4. Please expect 2 weeks to adapt to vision in new glasses. If there is a problem or change in prescription, lenses can be redone within 60 days from the first time glasses were purchased at no additional cost, after that you will have to pay in full.
5. Warranty on frame is one year from time of purchase. Warranty covers manufacture defect and not normal wear and tear or misuse of frame.
6. If you choose to use your own frame, Kapolei Eye Care takes no responsibility if the frame is damaged while being processed. You understand that if the frame breaks, Kapolei Eye Care will not be able to replace it or offer any monetary compensation.
7. Glasses and outstanding balances must be paid in full at time of pick up.
8. Glasses must be picked up within 3 months of completion otherwise it will be donated and balance will be forwarded to you.
9. All additional upgrades to lens, frame or other appliance options or services that are not covered by your insurance is the patient's or parent/guardian's responsibility and payment in full will be required before initiating the job.
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 Name Last Name
Patient's Date of Birth *

Month Day Year
Date *

Month Day Year
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 Name Last Name
Relationship to Patient
Should be Empty: