Tinted Lens Waiver Form
Please complete the Tinted Lens Waiver Form to acknowledge and authorize your tinted lens service.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Service or Appointment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Lens Type / Service Requested
*
Prescription Provided?
*
Yes, prescription is provided
No, non-prescription lenses
Prescription will be provided at appointment
Tinted Lens Acknowledgment: I understand that tinting lenses may affect visibility, color perception, or performance depending on lighting conditions and use. I acknowledge these factors and accept responsibility for my choice to receive tinted lenses.
Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
Should be Empty: