***********copy and present this form to your eye doctor************

Contact Lens Prescription Release

To:__________________________________________ doctor's name

Please forward a copy of my contact lens prescription, including all information necessary to dispense duplicates of the lenses I now use, including expiration date and number of re-fills. Prescriptions must be on doctor's stationary or Rx pad and should include license number.

CyberLens Contact Lens Services
3324 State Street, Suite J
Santa Barbara, CA 93105

This is a formal request for release of my records.

CyberLens offers a check-up reminder service. If you include the date I am due for my next check up, they will notify me one month prior by e-mail and I will schedule an appointment for follow-up care.

CyberLens we will not honor order requests without a current prescription or if, in the doctor's opinion, the patient is non-compliant with accepted lens care and should not be serviced by the company. Your input is always welcome.

CyberLens is operated by an optometrist and may be contacted by fax or voice at 805-682-1976 or e-mail: eyecare@west.net

Thank you.
 

___________________________________________patient name

___________________________________________signature ___________date