Toronto Eaton Centre

(416) 971-8355

Woodbine Centre

(416) 798-8908

Broadview Eyecare

(416) 466-6670
 

CONTACT LENS CONSENT FORM

Contact Lens Consent Form

I understand that I am purchasing replacement contact lenses. The contact lens prescription below was verified by an eye care professional within the last 2 years. I guarantee that the contact lenses below are fitted properly for my eyes. As such, I waive any responsibility from Dr. Archie Chung & Associates for the prescription, design and fit of these contact lenses, other than manufacturer defects. By signing this waiver I agree to all terms and conditions in our store policies.

EXPERIENCING TECHNICAL DIFFICULTIES? PLEASE DO NOT WORRY!

If you can not complete our insurance consent form because you're currently experiencing any technical difficulties, please do not worry! Please inform our clinic of any challenges. We can also assist you directly in clinic. We are always striving to improve. If you have any questions or concerns, please contact us. Thank you.

Please remember to ensure your browser is up to date, clear browser cache and cookies and turn off any adblocker browser extensions to see if that resolves any technical difficulties.

FOR NEW & RETURNING PATIENTS, PLEASE USE OUR PATIENT PORTAL TO BOOK AND REQUEST AN EYE EXAM APPOINTMENT ONLINE


Our secure online patient portal grants access to existing patients to book appointments online, provide eye health history, communicate with your eye care clinic and more. For convenient service, login today! Contact us directly if online access has not been granted or for any questions.

Appointment

Appointment