Optical Appointment Request Form

I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail, and any kind of online communications, provided that these communications comply with privacy regulations.


Appointment Reminders, Reschedules, and Cancellations

I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".

Telemedicine Appointments

For telemedicine, I understand the appointments will be held via electronic environments.


Contact Information Change

I accept that I am responsible for notifying the Company when my contact information change.



Consent Cancellations

I know that I can revoke this consent at any time by contacting the Company.



I consent to the use of mobile phone communications.


I consent to the use of texting (messages) communications.


I consent to receive electronic notifications for confirming, rescheduling, or canceling my appointments.

I sign this consent form on the behalf of

Myself/My family/Someone as a legal guardian