For Optical Freedom



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:
Text:
Email:







  Signed,  _________________________________________________________________________________
                           Authorized Signature                                                                                              Date







Spectacle Shoppe, Inc., 306 N Rock Road, Ste 10, Wichita, KS 67206