Prescription Release & Waiver

I understand that by filling my spectacle prescription with any other optical company other than Johnson Eyecare and Eyewear, I take full responsibility for my purchase and release Johnson Eyecare and Eyewear and their providers of any liability or complications that may result from that transaction which may include but is not limited to inaccurate pupillary distance measurements (PD), inaccurate segment bifocal height measurements, improper or unsafely manufactured lenses and/or prescription changes. Johnson Eyecare and Eyewear will only release the most current measurements and prescriptions that are on file and that have not expired per the provider’s discretion.

I understand

Patient Name*

Patient Date of Birth*

Today's Date*

Upload Photo ID for Verification*

Max. file size: 1 GB.