Frame and Lens Responsibility Waiver
I agree to the following:
Responsibility Release When Frame is Sent To Laboratory: By using my existing frame to insert new lenses, I understand that there is a possibility that the frame may be damaged or broken at the laboratory during insertion of the new lenses. Professional VisionCare has educated me on this risk and I do not hold them liable for any damage that may occur to my frame.
Responsibility Release When Frame Is Adjusted in Office: I understand that my frame is no longer new and may break when adjusted. If breakage occurs during adjustment or repair, I will not hold Professional VisionCare liable.
Responsibility Release When High-Index Lenses Are Selected: I understand that impact resistant lenses (also known as polycarbonate lenses) are recommended for the protection against shattering. I have elected to wear a High-Index lens, which is not impact resistant. I understand that Professional VisionCare recommends polycarbonate lenses for my safety. I will not hold Professional VisionCare responsible for any damages (including physical harm) due to breakage of a High-Index lens.
Other
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Patient Signature
Optician Name
First Name
Last Name
If you would like a copy of this waiver, please enter your email address and a copy will be sent.
example@example.com
Submit
Should be Empty: