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  • Dr. Bream & Associates

    FORM 9: CONSENT TO USE EXPIRED PRESCRIPTION

    OR

    FROM ANOTHER DOCTOR

  • Welcome to our clinic. We are pleased to offer this service to our patients in order to reduce the waiting times and the exposure in a public setting.

    The information provided is strictly confidential.

    Please fill out this application completely to the best of your ability.

    A copy will be sent to your email address given in this form.

    Thank you
    EYETELLIGENCE Team

     

  • Today's Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • ACKNOWLEDGEMENT

  • I, {nameas}, authorize EYETELLIGENCE to use the below Prescription to order my lens:*
  • Prescription Date:*
     - -

  • EYETELLIGENCE team made me aware of the below:

    1. For the optical prescription to work optimally, the Canadian Association of Optometrists recommends that the expiry date should not be longer than 2 years or exceed the expire date on the prescription. 
    2. Prescription can change over time due to aging and medical conditions like diabetes, blood pressure, and cataract, among others. EYETELLIGENCE recommended me to do a fresh eye exam prior to my order.
    3. An older, expired or the prescription from another Optometrist may not provide the desired results for my vision correction. EYETELLIGENCE or the Dr. Bream & Associates CAN NOT be held responsible in the event the new glasses not meeting my expectation.

    I understand the purpose for the above statement and agree. I understand that I can refuse to sign this consent form or purchase from another optical store.

  • Signature Date*
     - -
  • Should be Empty: