Prescription Delivery Consent

Prescription Delivery Consent
I consent to receive my eyeglass and/or contact lens prescription(s) electronically via the patient portal. If I request to receive my prescription(s) via email, I acknowledge that this method may not be secure or encrypted.
I consent to electronic delivery.*
Date*

MonthDayYear

Hour MinutesAM/PM Option
Is the patient under 18 years of age or have a legal guardian?*
Patient Name*
Patient Email*
Patient Signature*

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Parent or Guardian Name
Parent or Guardian Signature

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Prescription Receipt
If you do not consent to electronic delivery, please sign below to acknowledge receipt of your prescription(s) after completing your eye examination. For contact lenses, prescriptions are finalized after successful completion of insertion and removal training.
Patient Signature

Clear
Parent or Guardian Signature

Clear
Should be Empty:

Prescription Receipt