Glasses Prescription Received Acknowledgement Form
Eyes of East Sacramento
Answer Yes or No: I would like my eyeglasses and/or contact lens prescription sent to me electronically via email.
Yes
No
Recipient Information
Sign below to acknowledge that you were provided with a copy of your eyeglasses prescriptionimmediately after completing any refractive eye examination.
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Recipient's Signature
Submit
Should be Empty: