Contact Lens Fitting and Purchase Waiver Form
Please complete all sections to proceed with your contact lens fitting, purchase, and waiver acknowledgment.
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 Fitting
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Lens Type
*
Please Select
Soft Lenses
Rigid Gas Permeable
Daily Disposable
Extended Wear
Other
Prescription Details (if available)
Preferred Purchase Option
*
Purchase at fitting
Order for later pickup
Order for delivery
Delivery or Pickup Details
Waiver Acknowledgment
*
Signature (Type your name to acknowledge)
*
Date of Waiver Acknowledgment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: