Refund Waiver Form

Refund Waiver Form

Specsavers Southcentre - Theo Buzea Professional Corp - Southcentre Mall 100 Anderson Rd SE Calgary, AB, T2J 3V1
I, the patient hereby named below, understand and acknowledge that SouthCentre Specsavers/Theo Buzea Professional Corporation are providing me a full refund for the service provided. This has been done as a courtesy of the clinic to the patient. Upon completion of this refund, I agree to release SouthCentre Specsavers/Theo Buzea Professional Corporation, any of their associates, employees, contractors or any entities under them for any damages or costs that could arise and are associated with services or guidance given by SouthCentre Specsavers/Theo Buzea Professional Corporation or any entities under them (i.e. such as those listed above, but not limited to). The services and guidance referred to include, but are not limited to anything related to the optical and clinical portion of the clinic.*

I agree and understand
My signature below is an affirmation that I understand all the terms listed and agree to abide by them. Furthermore,it is an indication that I fully agree to waive all the rights to any claims that I had in the past, have in the present or may come up in the future. This release extends to any claims made with any regulatory body in relation to the services and guidance provided by Specsavers SouthCentre/Theo Buzea Professional Corporation or any of the entities under them. This includes, but is not limited to any Optometric and Optical regulatory bodies in Canada.*

I agree and understand
As this is an agreement between the patient and SouthCentre Specsavers/Theo Buzea Professional Corporation, I agree to full terms of confidentiality. For clarity, all matters listed on this waiver and related to it will not be shared with anyone else. This includes,but is not limited to: friends, family, public individuals, public media,courts of law. I acknowledge that this confidentiality further extends to any services and guidance provided to myself by SouthCentre Specsavers/Theo Buzea Professional Corporation. I understand that if a court order requests the details or SouthCentre Specsavers/Theo Buzea Professional Corporation requests the details, that I will be exempted from this confidentiality.*

I agree and understand
For clarity, this form is to release SouthCentre Specsavers/Theo Buzea Professional Corporation from any responsibilities and liabilities in relation to the patient listed below. This is not a declaration that there is any liability that is agreed to by SouthCentre Specsavers/Theo Buzea Professional Corporation or any of the entities under them (including, but not limited to associates, employees, contractors, etc.). The terms of this waiver are those listed on this page and no other terms were agreed to, verbal or written. Any previous agreements between the parties are nullified through signing of this form. Through completion by signing of this form below, it is an indication that the patient understands and acknowledges all terms outlined in this waiver and agrees to them.*

I agree and understand
Total amount refunded ($CAD)*
Please indicate what items/services were refunded*
Patient Name*

First NameLast Name
Patient Signature*

Patient signature indicates understanding and agreement to the entirety of the terms in this contract
Southcentre Specsavers/Theo Buzea Professional Corp Representative Name*

First NameLast Name
Southcentre Specsavers/Theo Buzea Professional Corp Representative Signature*
Today's Date*

DayMonthYear
Date
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