Glasses Form Optometrists in Wallingford, CT

Patient Consent Form for Electronic Delivery of Eyeglass Prescription

I, hereby consent to receive my eyeglass prescription electronically. I understand that this electronic delivery is in accordance with the Federal Trade Commission (FTC) rules, which requires the doctor to obtain consent for electronic transmission of prescriptions.

I understand that by providing my consent, I will receive my eyeglass prescription via email, secure online portal or other electronic delivery method.

I have read and understood the information provided and consent to receive my eyeglass prescription electronically.
Patient Name:
Date of Birth:

Patient Name:

Date of Birth:

Patient or Guardian Signature:

Date:

We strongly encourage that you speak with your doctor or Optician prior to purchasing eyewear online to avoid the following issues:

Incorrect prescription: A large study found that almost half of glasses ordered online had the wrong prescription, which can lead to blurred vision and discomfort.
Poor fit: Without a professional to help, it can be difficult to ensure that the glasses are properly fitted. This can lead to headaches, fatigue, and pressure marks on your face.
Quality control: Some online retailers may cut corners on quality control, leading to cheaply-made glasses that can worsen existing vision problems.
Pupil distance: It can be difficult to measure your own pupil distance, which is needed to order glasses.
Insurance: Some websites may not accept insurance.
Return policy: It may be difficult to return glasses ordered online.
Lack of personalized attention: Online retailers may not offer the same level of personalized attention and fitting expertise as a qualified optician.