Patient's Own Frame Waiver Form

Patient's Own Frame Waiver Form - Specsavers SouthCentre - Theo Buzea Professional Corporation
Patient Name*

First NameLast Name
I, (patient name indicated above), am fully aware of the risk of using my own frame for my order placed on the date indicated below. I release Specsavers SouthCentre, Theo Buzea Professional Corporation, any of their associates, employees, contractors or any entities under them for any liability, damages or costs that could arise and are associated with the use of my own frame.*

I understand and agree with the above statement
Today's Date*

DayMonthYear
Date
Signature*
Should be Empty:

Patient's Own Frame Waiver Form - Specsavers SouthCentre - Theo Buzea Professional Corporation