Patient’s Own Frame/Lenses Release Form Although we use the utmost care when handling your frame(s) and/or lenses, there are many factors that go into why a frame may break, (i.e.: quality, age, frame material, etc...), or why lenses could become damaged. Occasionally, a frame will break in the process of adjusting it, or while manufacturing new lenses. Because we do not have control over these possible unforeseen factors, Fusion Eye Care cannot be held responsible for any breakage/damage to existing lenses and/or a patient's own frame. Fusion Eye Care is also not responsible for any loss of patients' own atent property, whether it be in transit, or otherwise. * I have read the above statement, understand it and wish to proceedHiddenDate MM slash DD slash YYYY Patient Name* First Last Patient Date of Birth MM slash DD slash YYYY Patient or Guardian Signature*
