Spectacle RX Release Form
I,__________________________________________________________________
Birth Date
Home Address:______________________________________________________
Street
______________________________________________________
City, State and Zip Code
Request and do give permission to Doctor ______________________________
to release my eyeglasses prescription and to have it sent as soon as
possible to
the Spectacle Shoppe, Inc.
The prescription may be transmitted via:
|
FAX: |
|
316-686-7665, |
|
Voice: |
|
316-686-6111, |
|
Email: |
|
info@krspecs.com |
|
Signed, ____________________________________________________________
Authorized Signature
Date
Spectacle Shoppe, Inc., 306 N Rock Road, Ste 10, Wichita, KS 67206
| 