Manufacturer
Line
Model
Color
Eye Size
Bridge
Temple
Frame Type
Cost



Manufacturer
Line
Model
Color
Eye Size
Bridge
Temple
Frame Type
Cost



Manufacturer
Line
Model
Color
Eye Size
Bridge
Temple
Frame Type
Cost


By signing the above patient accepts full responsibility for the frame(s). The frame(s) is expected to be returned in the same condition as was checked out. We ask that you return the frame(s) within 24 hours after check out, if not returned patient will be billed for frame(s) at full retail cost.



Notes