FORM7: Patient’s Own Frame & Lenses Waiver Form

FORM7: PATIENT’S OWN FRAME / LENSES WAIVER FORM
Welcome to our clinic. We are pleased to offer this online form 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

MonthDayYear
Title
Name (As shown in your in your health card)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone
Format: (000) 000-0000.
Email
Invoice Number
POF Brand & Model
Size
Color
Rows Years Months

Age of the frame

Rows	Years	Months
Age of the frame

ACKNOWLEDGEMENT
At Eyetelligence, we are committed to providing you with the highest level of care and precision when handling your frame(s) and lenses. While we take every precaution, it is important to recognize that a variety of factors—such as frame quality, age, material, and authenticity—can contribute to unexpected breakage or damage.

Occasionally, frames may scratch or break during the adjustment process or while manufacturing new lenses. Since these outcomes stem from factors beyond our control, Eyetelligence Inc. and Nikon/Hoya Canada cannot be held responsible for any breakage or damage to existing lenses or a patient’s own frame.

Additionally, please note that older frame styles are often discontinued by manufacturers, and replacement parts may not be accessible. This limitation may affect your ability to repair or replace your frame if breakage occurs.

If your frame happens to break during the lens insertion process by Nikon or Hoya Canada, the custom lenses made for that specific frame cannot be reused in a different frame style. Each lens is designed uniquely to your prescription and the structure of your frame.

In such cases, Nikon/Hoya Canada will be happy to produce new lenses for your new frame at no additional charge. However, the cost of the replacement frame will be your responsibility. This doent apply to a breakage after the delivery of the frame to the patient.

Eyetelligence Inc., Hoya, or Nikon Canada are unable to offer reimbursement for damaged frames. We are also not responsible for any loss of your property, whether in transit or otherwise.

Please be aware that the lens warranty does not apply to lenses fitted to patients’ own frames.

Any frame purchased in the past from Eyetelettgence also considered to be POF.

If you have read and understood the information above and wish to proceed, we kindly ask you to complete and sign below.

Thank you for trusting Eyetelligence with your eyewear needs. Our team remains dedicated to ensuring a successful experience for every client.
For Eyetelligence Team

1. Carefully inspect ALL Patient's Own Frames (POF) orders and record ALL necessary remarks below.

2. Ensure this form is fully filled & signed by the customer for each POF order and attach it to the patient’s file.

3. Please also include CLEAR photos of any identified scratches, damage, etc. to this form.

4. If you have concerns about the age, condition, or authenticity of a frame, we encourage you **NOT** to accept the POF order.
REMARKS

Ensure the pictures are clear. Keep the temple fully open. Ensure to capture the writings on the temple. Add any notes on scratches, fading, cracks, issues with hinges and the overall condition. ENSURE TO DOCUMENT THE BRAND, MODEL AND THE SIZE.
Front view
Image

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Notes
Back view
Image

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Notes
Side view - Left
Image

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Notes
Side view - Right
Image

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Notes
Name (First Last)
Patient or Guardian Decision Maker
Signature Date

MonthDayYear
Signature
Staff Member First Name
Signature Date
Signature
Should be Empty:

For Eyetelligence Team

REMARKS