PrescriptionReleaseAuthErisation Name * First Name Last Name Date of Birth * MM DD YYYY Address * Email * Phone * (###) ### #### Optometry Practice * Please provide the name and location of the Optometry Practice you wish to request the prescription from. Permission * I give authority to Spex in the City Optical Dispensary to acquire my optical prescription using the details above and give permission to be contacted if further confirmation is required. Thank you! We’ll be in touch as soon as we have your prescription.
