This DOCX Microsoft Word document template is an example of a form that can be used if you choose to have patients sign a separate form to acknowledge receipt of the patient’s contact lens prescription.  You can also create your own form or download this template.  The FTC does not require specific language to be used but recommends, “My eye care professional provided me with a copy of my contact lens prescription at the completion of my contact lens fitting.”  Additional language can be included on the form.

This is the same template as the one featured in the Contact Lens Rule Compliance Toolkit, as published by the American Optometric Association in July of 2020. 

This is a Digital Download product.