1800 contacts· - Federal Trade Commission...Fax Server 1800 contacts· Dear Eye Care Pro i er, We are request in!• t e contact lens prescription for the following customer pursuant

RFS-0 1 3252015 60703 PM PAGE 11001 Fax Server

1800 contactsmiddot Dear Eye Care Provider

We are requesting the ortact lens prescription for the following customer pursuant to the Fairness to

contact Lens Consumerf

the contact lens prescrip

has authorized 1-800 C0

order verification requJs

Please either (A) send ul Isend back to us the Presc iption Form below including all parameters applicable dates and signature

The actual prescription bPrescription Form should be sent to our toll-free fax number 1-888-407-2020

by 04012015 Please r

I Patient Name

turn this form even if the parameters below are correct

Address middot shy

dsmiddot 2 p

BrandManuf curer Power Base Curve Diameter CyiAdd Axis

00 I 1-Day Acuvue

I OS I 1-Day AcuvuJ ~

I Exam Date I I

I Rx Issue Datebull I I

I Rx Expiration Date I I

Doctors Signature

The term Oe Is th1

bull bull Abseot volid medicol reaso t longer prescription len~hs the r

for deviating from the default p e s

documented and attached No t

~ct (Public Law 108-164) which requires the prescriber to provide a copy of

1on to any person designated to act on behalf of the patient This customer

TACTS to request this information on hisher behalf This is not a contact lens

copy of the customers actual prescription or alternatively (B) complete and

oist (90pk) I -37S I 8so I 142 I ooo lo J

oist (90pk) I -375 I 85o I 142 Iooo lo J

I I I I I I I J y yM M 0 0 y y

tY

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I I I I I I I I M M 0 0 y y y y

te on which the patient receives a copy of the prescription at the completion of their contact lens fitting

e prescription cannot expire Jess than one year after the issue date in any state (or In states that permit

scription cannot expire before the date specified by the state) If the prescriber has a valid medical reason

ription length under state Jaw at the time the prescription was issued we ask that the medical judgment be

at this information may be provided to the patient

1133124

RFS- 03 3262015 100436 AM PAGE 11001 Fax Server -

1800 contactsmiddot

middot middotmiddotmiddotbull Dear Eye Car~ P~v pr bull middot

We are r~questing lh~contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consu~n ers Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens prJs ription to anyperson designated to a~t on behalf of the patient This customer

has authorized 1-8do CONTACTS to request this information on hisher behalf This is not a contact lens d fi middot Ior er ven 1cat1on rq est

us a copy of the customers actual prescription or alternatively (B) complete and Please either (A) se(ic

send back to us therescription Fornl b~low including all parameters applicable dates and signature

The actual prescript)c nor Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 04022015 Pl~a e return this form even if the parameters below are correct

I bull I

Patient Name Address

---~

BrandMan facturer Power Base Curve Diameter CVIAdd Axis

OD I Biofin~y 6 I -325 I a6o 1140 Iooo lo I I

OS rBiofinity Jp I -300 I a6o I 140 Iooo lo I

Exam Date I I I I I I I I M M D 0 y y y y

Rx Issue Datebull 1 1 1 I I I I I M ~ 0 0 y y y y

Rx Expiration Date

Doctors Signature

The term uRx Issue Date Is


h date on which the patient receives a copy of the prescription at the completion of their contact lens fitting

bullbullAbsent avalid med1cal rea Jon get prescription lengths t

for deviating from the defaul

documented and attached

o the prescription cannot expke les than one year after the issue date in any state or in states that perm1t

e prescription cannot expire before the date specified by the state) If the presctiber has a valid medical reason

p escription length under state law at the time the prescription was issued we ask that the medical judgment be

o e that this information may be provided to the patient

1141298

RFS-01 3262015 1 23 56 PM PAGE 1001 Fax Server

1800 contacts Dear Eye Care Pro i er middot

We are requestin~ t e contact lens prescription for the following customer pursuant to the F~irness to

Contact L~ns Consu ners Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pfe cription to any person designated to act on behalf of the patient This customer

has authorized 1-10 CONTACTS to request this information on hisher behalf This is not a contact lens

order verification re uest

Please either (A) sf d us a copy of the customers actual prescription or alternatively (B) complete and

send back to us the rescription Form below including all parameters applicable dates and signature

The actual prescritt on or Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 04022015 Pi se return this form even if the parameters below are correct

Patient Name is~bullbullbullbullbull Address~ Qk 2 F -

OD

Brand

I Biofinit

a ufacturer

pk

Power

I -3zs

Base Curve

I s6o Diameter

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Rx Issue Datebull

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Rx Expiration Date I I I I I I I I M M D D y y y y

Doctors Signature

bullbullAbsent a valid medical a on the prescription cannot expire less than one year after the issue date in any state or in states that permit

longer prescription length he prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reason

for deviating from the def u prescription length under stat~ law at the time the prescription was issued we ask that the medical judgment be

documented and attache ote that this information maybe provided to the patient bull - 1144062

I I - 0bull~t ~ RFS-03 5272015 70349 AM PAGE 1001 Fax Server

_ bull

middot

-- ---middotshy

Dear Eye care Provi e

We are requesting t~e contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consu1 rs Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens presc iption to any person designated to act on behalf of the patient This customer I bull

has authorized 1-800 DNTACTS to request this information on hisher behalf This is not a contact lens

order verification re4t est

Please either (A) sen~ ~sa copy of th~ ~stomers actual prescription or alternatively (B) complete and

send back to us the tscription Form below including all parameters applicable dates and signature

The actual prescripti or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 1

by 06022015 Pleas return this form even if the parameters below are correct

I ~

o- a~ 0 el ~ U II U _ I

Patient Name ~~bullbullbullbullbullbulla Address -lHoililmiddotlililiiiil]tlliJIPP

BrandMa u acturer Power Base Curve Diameter CVIAdd Axis

OD I Acuvue A v nee for Astig 6pk I -600 I 86o I 14s I -175 I 30 I

OS I Acuvue A v nee for Astig 6pk I -550 I 86o middotI 145 I -175 1140 I

Exam Date I I I I I I I I y y y yM M D D

Rx Issue Date I I I I I I I I y y y yM M D D

Rx Expiration Date I I I I I I I I y yM M D D y y

Doctors Signature-+-----------------------shy

The term Rlt Issue Date] t e date oo whkh the patieot receives a copy of the premiptioo at the completioo of their contact le fittiog

Absent a valid medical re s n the prescription cannot expire less than one year after the issue date in any state (or in stteS that permit

longer prescription lengths n prescription cannot expire before the date specified by the state) lfthe prescriber has a valid medical reason

for deviating from the defa It rescription length under state law at the time the prescription was issued we ask that the medical judgment be

documented and attached N te that this information may be provided to the patient

1469168

RFS-01 4222015 41550 PM PAGE 1001 Fax Server

1800 contactsmiddot Dear Eye Care Pro i er

We are request inbull t e contact lens prescription for the following customer pursuant to the Fairness to Contact Lens Cons~1rers Act (Public Law 108-164) which requires the prescriber to provide a copy of the contact lens p e cription to any person designatedmiddot to act on behalf of the patient This customer has authorized 1- 0 CONTACTS to request this information on hisher behalf This is not a contact lens

order verification fle uest bull

Please either (A) s d us a copy of the customers actual prescritiomiddotn or alternatively (B) co~plete and send back to us th rescription Form below including all parame~ers applicable dates and signature

The actual prescript on or Prescription Form should be sent to our toll-free-fax number 1-888-407-2020

by 04292015 P e se return this form even if the parameters below are correct

Patient Name1 Address

lt4 3 shy

1Brand nufacturer Power Base Curve Diameter CVIAdd Axis

OD r Dailies tal190~k I -35o I sso I 141 I ooo lo I OS bull r Dailies tal190pk 1 -275 -r sso 1141 Iooo lo I

bull - 1--__LI __ I I I I IExam Date _]__~_L_ __l_~L--_L~-_L--_JImiddot I

M M D D y y y y

~ i

~middotmiddot Rx Issue Datebull IJL__ bull I I l ___ I JI___--~-------JI I I_L_____~____JL_ ______

M D y y y yM ~ ~

R~ Expiration Date 1[L[ ___L_I _ I I I ___LI___JI___LI JI_l-~L___L ___

bullt- bull M M D D bull y y y y

Doctors Signature 1-1------------------------shy

bullThe term RXIssue Oat sthe date on which the patient receives a copy of the prescription at the completion of their contact lens fitting

bullbullAbsent a valid medica r ason the prescription cannot expire less than one year after the issue date in any state or in states that permit longer prescription Ieng hs the prescription cannot expire before the date specified by the state) If the prescriber has avalid medical reason

for deviating from the d t It prescription length under state law at the time the prescription was issued we ask that the medical judgment be documented and attach d Note that this information may be provided to the patient

1235718


Dear Eye care Pr ider

We are requesti~e the contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Cons mers Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens~ escription to any person designated to act on behalf of the patient This customer

has authorized 1[ 00 CONTACTS to request this information on hisher behalf This is not a contact lens

order verificatioj~ equest

Please either (A) s nd us a copy of the custo~ers actual presciiption or alternatively (B) complete and

send back to us h Prescription Form below including all parameters applicable dates and signature

The actual presc[l i tion or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 by 04272015 Pease return this form even if the parameters below are correct

Address ~=ai_ 1 0 Pte s~

Power Base Curve Diameter CVIAdd Axis bull IOD bull -300 I 83o I 14o I ooo lo

OS Acuv 2 (6pk) I -3so I 83o I 14o I ooo Io

Exam Date I I I I I I I I M M D D y y y

Rx Issue Datebull I 1 I I _ l I I I M M D D y y y y

Rx Expiration Date I I I I I I I I I M M D D y y

Doctors Signatur

bullThe term Rx IssueD t is the date r()l whi~h the patient receives a copy of the prescription at the completion of their contact lens fitting

bullbullAbsent a valid medi a[ reason the prescription cannot cxrNe less than one year after the issue date in any state or in states that permit

longer prescription len s the prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reason

for deviating from the e ault prescription length under state law at the time the prescription was issued we ask that the medical judgment be

documented and atta e Note that this information may be provided to the patient

1220071

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1800 contacts

Prescription Reques middot

Patient Name

Fax the completed form to (888) 407-2020

Prescription Form

Address

OD

OS

BrandMa acturer

I ClearSigh~ 1 Day 90 pk

I l ClearSigh~ 1 Day 90 pk

Power

I -325

I -325

Base Curve

I a7o

I a7o

Diameter

I 142

I 142

CyiAdd

I ooo

Iooo

Axis

Ia

lo

I

J

Exam Date I I I I I I I y yM M D D y y

-l -

Rx Issue Date I I I I I I I I M M D 0 y y y y

Rx Expiratioil-Date- shy I middotI- I I I 1- I I M M D D y y y y

Doctors Signature

ECP Information If o r office information below is incorrect or missing please correct it or fill in the blanks here orb an accompanying fax

Business Name

Doctor

Phone

~ Fax

Email

-I

Pearl John o

7733

7733

I I The term

6 RX Issue Date rt

J Absent a valid medical rea si longer prescription lengths h for deviating from the defa


~1

It

ision Office Address

Grote OD Andrea State

3000 City

3015 Zip

Saturday Hours

1730 West Fullerton Avenue Suite 1 IL

Chicago

60614

e date on which the patient receives a copy of the prescription at the completion of their contact lens fitting

n the prescription cannot expire less than one year after the issue date in any state or in states that permit

prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reaoon

rescription length under statelaw at the time the prescription was issued we ask that the medical judgment be

N te that this information may be provided to the patient

1018121 I

I

RFS-01 2162015 112647 AM PAGE 2002 Fax Server

1800contactsreg Prescription Reques Fax the completed form to (888) 407-2020

Prescription Form 1

IPatient Name Address

bull BrandMan facturer Power Base Curve Qiameter CyiAdd Axis

00 -225 830 140

OS Acuvue Ahv nee (6pk) -275 830 140

Exam Date

y y y yM M D D

1 Rx Issue Datebull M M D Dmiddot y y y y

Rx Expiration Date

M M D D y y y

Doctors Signature ECP Information It yo r office Informationmiddot below is Incorrect or missing pleasecoirect it or fill in the blanks here

orlo an accompanying fagt

Business Name Pear e islon Office Address F30 West Fullerton Avenue SuitE 1

Doctor John o Grote 00 Andrea State IL

Phone 7733r 3000 City Chicago

Fax 77332 3015 Zip 60614

Email Saturday Hours

bull The term Rx Issue DattiI e date on which the patient receives a cooy of tile prescr~ption at the completion of their contact lens fitting

Absent a valid medical r as n the ~rescrption cannot expire less than one year after the issue date in any state (or in states that permit

longer prescription lengths ~ prescription cannot expire befom the date specified by the state) If the prescriber has a valid medical reason

for deviating from the defa It rescription length under state law ~t the time the prescriptio~ ~vas issued tve aslc that the medical judgment be

documented and attached N te that this bfonnation may beprovided to the patient

990352

2242015 24402 PM PAGE 2002 Fax ServerRFS-03

1800 contacts

I ) i

=i

1

Prescription Reques Fax the completed form to (888) 407-2020

Prescription Form

Patient Name

_

middot~ middotr~

BrandMa u acturer Power Base Curve Diameter CyiAdd Axis

OD I Focus Daiie 90pk I -3oo T86o I 138 I ooo lo I

OS I Focus Dailie 90pk I -275 I 86o I 138 I ooo lo I

0 I I I 2 I I 1()1131Exam Date

y y yM M D D

Rx Issue Date () I I 17 I 177 I n I I I 6 I y y y yM M D D

o I l 15 T I 7 I () I I ll IRx Expiration Date

y y y yM M D D

Doctors Signature ECP Information lf(O r office Information below IS Incorrect or mtssing please correct tt or f1ll1n the blanks here

orr an accompanying fax

Business Name Pearle Stan Office Address 1730 West Fullerton Avenue Suite 1

Doctor State IL

Phone 7733

Johnto Grote OD Andrea

3000 City Chicago

Fax 7733 3015 Zip 60614


The term Rx Issue Date IS e date on which the patient receives a copy of Hie prescription at the completion of their contact lens fitting

Ab volld medkbulll r~as n the preso6ption cooootexpire le th one yef bullfterthe isoe date in gtny ate or in e thbullt permit longer prescription lengths th prescription cannot expire before the date specified by the state) lf the prescriber has a valid medical reason for deviating from the defa It rescription length under state law at the time the prescription was issued we ask that the medical judgment be


1020342

-1 -1


1800 contacts Prescription Request ax the completed form to (888) 407-2020

Prescription Form


l BrandMa u cturer Power Base Curve Di~er CyiAdd Axis

I 1

OD [ AirOptixf r stigmatism 6pk [ -700 I s1o I 14s I -125 1180 I

OS I Air Optix thr ~stigmatism 6pk [ -700 I 87o I 145 I -o75 1180 I

Exam Date I I I I I I I I y y yM M D D

Rx Issue Datebull I I I I I I I I y y y yM M D D

Rx Expiration Date I I I I I I I I M M- D D y y y

Doctors Signature ECP Information If o r offtce information below Is mcorrect or missmg please correct 1t or f11l m the blanks here

or an accompanying fax

Business Name IS Lon Express Office Address 1730 West Fullerton Avenue

Doctor ee State IL

Phone 7733 7 000 City Chicago

Fax 7733 015 Zip 60614


bull The term Rx Issue Date i t e date on which the patient receives a copy of the prescription at the completion oftheir contact lens fitting

Absent a valid medical re s n the prescription cannot expire less than one year after the issue date in any state or in states that permit

longer prescription lengths h prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reaOn

for deviating from the defa t rescription length under state law at the time the prescription was issued we ask that the medical judgment be 1

documented and attached te that this information may be provided to the patient

1020792

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FFS-middot03 3102015 101618 AM PAGE 2002 Fax Server

1800 contacts Prescript on Request ax the completed form to (888) 407-2020

Prescription Form

I JiE n Name Address


00 l Acu~ue Ad~v nee (6pk) I -375 I 830 I 140 I000 I0 I

~~ ---H----I I I L I I

r-------T--1 I I I I I J bull1 1 0 9 y y y y

middot -~ c I I I I I I I I M 1 f) 0 Y Y ( Y

middotat on Date I I I I I I I I M 1 0 gt V V Y Y

) ~-- S nature __ 1------ middot---------------------------_-----shyr middot-n ltgttion If y r offic2 irformation blow i incorrect or missing please correct it or fill in the blanks here

or centIn an ccompanying fagt

Ptlt~rrl~ l ii me ision OfficeAddress 1730WestFullertonAvenue ~ Suite 1

Johns GrotE OD ~ndra Stlt~te ll

7i33 7 000 City Chicago

-middotmiddotmiddot

73 7 015 Zip 60614

Saturday Hours

middotJo sJe Ditlt t e date 01 ~- - t1e ocmiddote~bullt middotcmiddotceve~ a cogty of te orecription at tOe completion of their contact lens fitting

J d Titod J s ~ -~ gtt IJJ ltlfllgt 1

middotmiddotmiddotf imiddotu-n 1-1~ defbullr t ~ bull ( a1d atta middot(j

n tne )c bullmiddot ~fa CiJbull)t~xbullltJ ess tilan onevear after the issue date in any state (or in states that permit

Pe$cmiddotmiddotot igtl c~ mote~~~ nefNH the date gtPetiLed by the state) If the prescriber has a valid medical reason

escbullltomiddot~ gt1 1~demiddot stilte oaw at the time t1e rescripton was issued we ask thatthe medical judgment be

e tl1t 1middot1middotmiddot lhY11aton middotny bbull orovded to the latient

1074933

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l -~ middot- ~ l 3102015 102223 AM PAGE 2002 Fax Server

1800 contacts 0 r2cript on Re~~est Fax the completed form to (888) 407-2020

Prescription Form

Address) t_ _ -middot 11

BraodVfvlan ufactcrer Power Base Curve Diameter CyiAdd Axis

middot--1~~ ss op~==r~- __L7o I 14 2 Iooo Io I~ ~

-5- Frtf~incy 55 6plt -5 7S 870 142 000

~-

-~1 middot-lttate~

1 bullbull )

S 1middot tur

ron~

middot Nme

i -==]____ _ J Jmiddot

c~~--~~--~~~~ - middotl 0 y

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if your effie ufvr-ation below 1$ incorrect or missing please correct it or fill in the blanks here c-r on an accunll)my~ng fagt

liltHie ViSion middotoffice Address 1730 West Fullerton Avenue Suite 1

_ Jbhnson Grott OJ ~ndrea State ll

73327300C Ci~ Chicago

733273015 Zip 60614

Saturday Hours

i middot middot i~ic ICmiddotJtbull middot$ t -~ d e-middot __ middotmiddot 1-~ oale~t bull Cmiddotmiddot eS a coly or toe lrescrioFon at the completion of their contact lens fitting

I l -~ ~0 1 tl~ )e~middot =too C3nnot ex middot~ ess than on~ year after the issue date in any state or in states that permit3

middot r1bull1 1 1 1 1 llt )bullmiddotmiddot 1 1middotc 11CLexi~~ lfltYt~ tmiddot1e date soecfed by the stale 1r tne prescrioer hltJ~ a valid medica reason

11 bull 1 I f t omiddot~~ middotl 1 ~ -g 11demiddot stat~ w atte tlTle t1e lescripton was issJed we ask tnat the medical Judgment be

Jt l Nvtl 111 t middotmiddotfbullmiddot-natioo nay Jbullovded to tfle gtatelt shygt 1075024

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r s-o 2 3112015 10126 PM PAGE 2002 Fax Server

1800 contacts Prescription Request F x the completed form to (888) 407-2020

Prescription Form

= Patient Name Address I I

BrandManufa turer Power Base Curve Diameter CyiAdd Axis

00 I Acuvue 2 (6 k I -7JO I 87o I 14o Iooo lo I

OS I Acuvue c t6h bull 1 -6oo I 87o I 14o Iooo lo I I

Exat ~ I I I I I I I Ill - M M D D y y y y

t

I R~ l~ch~ Catebull II I I I I I I I I

y y) M D D y y

I Rx pound1ratio[Date I l I I I I I Il

y yM M D D y y

0 middotss~nature Ec -fnation lfyo r office Information below Is Incorrect or missing please correct it or fill in the blanks here

001 n accompanyingfaX

Office Address 1730 West Fullerton Avenue Busirmiddots N1me Pwe~ i ion Suite 1

OoctGmiddot Johnso rotr 00 Andrea State IL

Ph ormiddot 7733213 00 City Chicago

Fax 7733273 15 Zip 60614

Ematbull Saturday Hours

o I d~te o1 whicn the patient receives a copy of the prescription at the completion of their contact lens fitting

middot middot ~~ent a 1a d medco middoteas n the Jbullescription cannot expire less than one year after the issue date In any state or in tates that permit

presmiddot ~ton lengh L 1 re~crltion cannot expire before the date pecified by the state) If the prescriber has a valid medical reason fo dviatinf IOTI tne def t ( scritol engtl under state law at the time the prescription was isued we a sic that the medical judgment be

de nentec 31d anacoo thgtt tlgt lforllation mai be provided to the patient

1081982

3112015 44607 PM PAGE 2002 Fax ServerRFS-0 2

1800 contacts Prescription Request F x the completed form to (888)407-2020

Prescription Form


~ 15W

BrandMaJ f eturer Power Base Curve Diameter CyiAdd Axis

cc I 1-Day Acuv e Moist (90pkl I -2SO I 85o I 142 Iooo l 0 l _ I 1-Day Acuv~e Moist (9Dpk) I -250 I 8so I 142 Iooo I o I

Date- I I I I I I I I I y y y yM M 0 D

II I I I I I I T l~- e Catebull

y y y yM M D D

(Expiration Date I I I I I I T I y y y yM M D D

Doer -bull- S1gnature f~rr1ation If yo r office information below is Incorrect or missing please correct it or fill in the blanks here

n accompanying faxoro

i ion Office Address 1730 West Fullerton Avenue ~ltf~ss Name Pearle~ Suite 1

_-(~ Johnson rate 00 Andrea State ll

DO City Chicagobull 77332t3

l 15 ZiP 60614

Saturday Hours

date on which the patient receives a copy of the prescription at the completion of their contact lens fitting n middotmiddotRx Issue ~ate is r t a valid med1cal reaso the prescription cannot expire less than one year after the Issue date in any state (or in states that permit

tscription lengths thle rescription cannot expire before the date specified by the state) If the prescriber has a valid medical reason

~middot~1g from the default pr scription length under state law at the time the prescription was issued we ask that the medical judgment be

1ted and attached N t that this information may be prov~ded to the patient

1085341

I


1800 contactsmiddot Dear Eye Care Pr v der

We are requesting he contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Con~ mers Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens 9r scription to any person designated to act on behalf of the patient This customer

has authorized 1-f 0 CONTACTS to request this information on hisher behalf This is not a contact lens

order verificatio~r quest

Please either (A) ~end us a copy of the customers actual prescription or alternatively (B) complete and

send back to us t Prescription Form below including all parameters applicable dates and signature

The actual prescrir ion or Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 07082015 rl ase return this form even if the parameters-below are correct

Patient NamJ ~- Address -

Exam Date I I I I 1 1 1 I J M M D D y y y y

Rx Issue Datebull I I I I I I I I I M M D D y y y

Rx Expiration Date I___L__JI___IL___ j_L____JI----------1----1I jL___ M M D D y y y y

Doctors Signatur +------------------------~--

The term Rx IssueD te is the date on which the patient receives acopy of the prescription at the completion of their contact lens fitting

Absent a valid medi al cason the prescription cannot expire less than one year after the issue date in any state (or in states that permit


fordevating from the e ault prescription length unde( state law at the time the prescription was issued we ask that the medical judgment be docunented and attac e Note that this information may be provided to the patient

1614797

IRFS-0 1 3172015 84207 PM PAGE 2002 Fax Server

1800 contacts Prescription Reques Fax the completed form to (888) 407-2020

Prescription Form

I Patient Name Address 709 W Armitage

CHICAGO ll 60614

BrandMa facturer Power Base Curve Diameter CyiAdd Axis

OD I 1-Day Ac v eMoist (90pkl I -750 I sso I 142 I ooo lo I

as I I I I I I I

Exam Date I I I I I I I I M M 0 0 y y y y

~ Rx Issue Datebull I I I I I I I I

y yM M 0 0 y y

Rx Expira~ion Date I I I I I I I I y y y yM M 0 0

Doctors Signature ECP Information r office Information below i~ incorrect or missine please correct it or flU in the blanks here lfJ0

an accompanying fax

Business Name Pe1 islon Office Address bull middotlt middot~c

1730 West Fullerton Avenue Suite 1

Doctor John[0 Grote CD Andrea ~stltite IL

Phone 77332 3000 middotmiddotti-~itV Chicago

Fax 7733middot 3015 Zip 60614


w The term RK Issue Date tS e date on which the patient re_ceives a copy of the prescription at the completion of their contact lens fitting

bullbull Absent a valid medica r Ia n the prescription cannotexpi~e less than one year after the issue date In any state or in states that permit longer prescription lengths th prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reason fOr deviating-from the defa It rescription length undersJt~~~~~ 1t the time the prescription was issued we ask that the medical judgment be

documented and attached N te that this informaiion may ~~~r0ided to the patient

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~e are reque~tinX e o~t~ctlens pr~scripi~n fo~middot-~~~mr pusuant to ~e ~~~ss tq

Contact Lens Cons~ rers Act (Public Law 10~-164) w~ich-requi(JSt_he prescriber to provide a copy of

the contact lens p~e cription to a_ny person de~igna~ed~o ~ct onb~~~alf of the patient This customer has authorized 1-80 CONTACTS to request thismiddotinfcirmation on hisher behalf This is not a contact lens order verification e uest - middot- middoty_

middot -middot -- _ middot-_lt-middotmiddot - 7middot- _middot-~_-_SJ---~f~~~~-~~1~~~iJ1f~~~slt-~( middot - middot middotmiddot---~- middot middot Please either (A) s d us a co~y ofthec~stol1)~rsactuaJprescrigtibn br alternatively (B) complete and

send back to us th rescription Form below inCluding all par~m~ers applicable dates and signature middot -~

The actual prescri middotton orPrescripiion Form shouid b~~~rit t~-outbii-free fax number 1-888-407-2020 -- - - - _ _ - - --- byOS112015 middotp e se returnthisforn) even if tlie p~~1mete~~b~l6ware correct

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Patient Name

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BrandM nufacturer ~oWer middotmiddotBas~middotcu(e~~gt- bi~_th_eter CyiAdd Axis

Exam Date omiddot 5 y y y

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Rx Expirati~n Date 0 y y y

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~ middot - middot bullThe term ~Rx rssue Oat s the dateon iVhich the PaiientreCeivesamiddot Copy of the prescriptibfl atfue completion of their contact lens fitting - - - - shy~

bull bull Absent a validmedica r asonthc prcgteriotion cannotcXoirc leSs tharione yltiJr artEir the issJa date-in any state (or in states that permit

longer presctiptio(llengt s the-prescriptionmiddotcrnn~t ~x-pir~ b~fore tM ci~te-spedfed oy th-e state) If the prescriber has a valid medical reason

fordevi~middotting -fr_om tl-i~ d fa rtpnscrjption leilgth ~~Oerstate law at th~-tirne the p_r~s~rpt7oAVils I~Ued we ask that the medical judgment be

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ConsLJineisAct (Public Law 108-164) iNhicheqiiires the prescriber to provi~e a ~opy of shy - _ - middot - _ ~- bull - middot- - middot _

orEscliotion ioany perscindesignai_eaioait cinbehalf of the patient This customer ~ f _bull bull bull bullbull middot-middot bull bull f_bull ~

onlhl-rTr-to request this Information onmiddothisher behalf This is not uontactlens - middot-middot~ -~-- middot middot- ~~- _ ~ middot

middot - bullbull bull f ) middot - middot -- middotbull middot - -

IAJsenidl us a copy of thecustomer sactual prescription or alternatively (B) complete and middot Plltgtltririmiddotntirm Form he low f~~~~dl~g -~llpar~inet~~fapplicable datesand sigria~ure

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1800 contacts Dear Eye Care Pro der

We are requestin~ he contact lens prescription for the following customer pursuant to the Fairness to

contact Lens conF mers Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens p r scription to any person designated to act on behalf of the patient This customer I

has authorized 1-8 0 CONTACTS to request this information on hisher behalf This is not a contact lens

order verification r quest

Please either (A) s nd us a copy of the customers actual prescription or alternatively (B) complete and I send back to us tJ Prescription Form below including all parameters applicable dates and signature

The actual prescn p ion or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 I

by 08132015 rI ase return this form even if the parameters below are correct

Patient NamJ Address ___J nufacturer Power Base Curve Diameter CVIAdd Axis

00 f Acuvub asys 12pk I -2so I 84o I 14o IODD lo I I

OS r Acuvu~ asvs 12pk I -22s I 84o I 14o IODD I0 I

docurncnted alt1d attach d Note that this informatiol may bf orovided to the patient

1807125

Exam Date I I I I r I I I I M M D D y y y y

-rRx Issue Datebull r I I I I I I I M D D y y y y


Doctors Signature

~rle term ~Rx Issue Oat s the date on which the patient receives a COIJY of the prescription at the completion of their contact lens fitting

bull bull Absent a vald med1ca r ason the prcscr1ption cannot eKpirc less than one year after the issue date in any state (or in stltes that permit longer prescription lengths the prescription cannot expire before the date specified by the state) If the prescriber has a valid medical reason

fomiddot deviating from the d fa It prescriptiollength under state 1aw at the time the prescription was issued we ask that the medical judgment be

I


1800 contactslt Dear Eye care Pr ider

We are requesti the contact lens prescription for the following customer pursuant to the Fairness to

Contact lens Co~s mers Act (Public law 108-164) which requires the prescriber to provide a copy of

the contact lens escription to any person designated to act on behalf of the patient This customer

has authorized 1 00 CONTACTS to request this information on hisher behalf This is not a contact lens

order verificatio~ equest

Please either (A) s nd us a copy of the customers actual prescription or alternatively (B) complete and


The actual prescli tion or Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 08112015 Pease return this form even if the parameters below are correct

Patient Namk Address

Brand anufacturer Power Base Curve Diameter CyiAdd

OD Focu ames 90pk -100 860 138 DOO

OS Focu ailies 90pk -100 860 138 000

Exam Date

Rx ISSUe Dlt~te

Rx Expiration Date

Doctors Signature +------------------------shy

bullrr1e term Rx Issue Da e is the date on which the patient receives a copy of the prescription at the completion of their contact lens fitting

Aosenl a valid medic I eason the prescription cannot expic less than one year arter the issue date in any state (or In states that permit

lor1ge~ orescbulliption len middoth the prescription cannot eKpire before the date specified by the state) If the presctiber has a valid medical reason

fo deviatng from the et uit prescription length under state aw at the time the prescription was issued we ask that the medical judgment be

doCIJmented and attac e Note that this information may be orovided to the patient

1787359


180c1 contactsmiddot Dear Eye Care Pro i er

We are requestint t e contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consl ners Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pe cription to any person designated to act on behalf of the patient This customer

has authorized 1-80 CONTACTS to request this information on hisher behalf This is not a contact lens f Idor er ven 1cat10n [e uest

Please either (A) s d us a copy of the customers actual prescription or alternatively (B) complete and

send back to us thl rescription Form below including all parameters applicable dates and signature

The actual prescript on or Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 08112015 Pie~se return this form even if the parameters below are correct

Patient Name Address middot111

BrandM nufacturer Power Base Curve Diameter cyiAdd A~s

OD I 1-Day Ac vue Moist (30pk) I -400 I B50 I 142 I ooo lo I

OS I 1-0avc vue Moist 30pk) ] -100 I sso I 142 I ooo lo

Exam Date i I I I I I I I I M M D D v v v

Rx Issue Datebull I I L I l I I l J M M 0 D v v y y

Rx Expiration Date 11--_ ___ J __L__J_ ___I___LI___L_______ _jl___J L 1 l M M D 0 v y y y

Doctors Signature H-------------------------shy

bullrne term ~Rj( Issue Oat s the dale on which the patient receives a copy of the prescription at the completion of their contact lens fitting

bullb~ent a valid medica r ason the prescription cannot eKpi~e less than one year after lhe issue date in any state (or in states that permit

longer presctiption lengt s the orescripton cannot expire before the date specified by the state) lfthe presctiber has a valid medical reason

for deviating from the d f3 It presc~iption iength under state aw at the time the prescription was issued we ask that the medical judgment be

docume1ted and attuch d Note that this itlformation may bC lravded to U1~ patient

1794510

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RFS-02 562015 3f010 PM PAGE 1001 FaxServer

middot middot

Dear Eye Care Provider

I We are requesting tr contact lens prescription for the followingcustomer pursuanno the Fairness to

Contact Lens Consum rs Act (Public law 108-164) which requires the prescriber to provide a copy of

the contact lens preF iption to any person designated to act on b~half of the patient This customer has authorized 1-800 ONTACTS to request this-information on hisher behalf This is not amiddot contact lens order verification re~ est - -

tgte~se either (A) se~d us a copy of the custom~rs actual prescri~tion or alternatively (B) complete and

send back to us the r~scription Form ~elm including all ~aramete~_s applicable dates and sigQature

Jhe actual prescriptO or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 ~ I

by 05132015 Plea ~ return this form eve~ if the parameterd below are correct bull middot - I

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bull (Rx Issue Date I I I I I I I I

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for deviating from the deta It ~escription length under st~tetaw at the tirile the pre~cripti6n Was issued we ask that tbe medical judBinent be - documented and attached N te that this information may be provided to the oatient

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Dear Eye Care Provi er

We are requesting~middot e contact lens prescription for the following customer pursuant to the F~irness to

Contact Lens ConsJn ers Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens prk cription to any person designated to act on behalf of the patient This customer

has authorized 1-Bb CONTACTS to request this information on hisher behalf This is not a contact lens

order verification rb_ u~~t _- _ ___lt middot middot- ) t -middot-- -~)-~middot bull middot Please eithe~ (A) ~ln~ ~sa ~opy of thecusters ~ciual ~rescription or alternative~ (B) complete and


middotThe actual prescri~ti nor Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 05142015 Pie se return this form even if the parameters below are correct

L _ middot middotmiddot cmiddotmiddot


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Exam Datebull I I I I I I L J M 0 y y y y

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Doctors Signature

The term Rx Issue Date i the date on which the patient receives a copy otthe prescriptiol at the completion of th~ir contact lens fitting

Absent a valid medical son the prescription cannot expire less tnan one yeltJr after the issue date in any state or in states that permit

longer prescription engt s he prescription cannot expir~ before the date soecified by the state) If the prescriber has a valid medical reason

for deviating from the de a It presCription lengthunder ~tate law at the tim~ the p~~scfipton was issued we ask that the fnedical j~dgment be

documented and attache Note that this informatOI may t~ orovided to the gtatient

middot

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Dear Eye Care Provide

We are requesting tt ~ontact lens prescription for ihe followinii customer pursuant to th~ Fairness to

Contact Lens Consu~ bull rs Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pre$c iption to any person designated to act on behalf of the patient This customer I

has authorized 1-800 ONTACTS to request this information on hisher behalf This is not a contact lens fi I

order ven 1cat10n req est

Please either (A) sen~ sa copy omiddotthe customers actual prescription or alternatively (B) complete and

send back to us the ir scription Form below including all parameters applicable dates and signature

The actual prescriptib or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 I by 05142015 Pleas return this form even if the parameters below are correct- I

Patient Name HI~-lllllaimiddot Address

BrandMao u acturer Power Base Curve Diameter CVIAdd Axis

bull bull Imiddot~middot 00 I I I I I Ibull I as Air oPtix ftq middota 6pk I -22s I sGo 1142 Iooo lo I

Exam Datebull bull I I I I I I I J bullM M 0 0 bull

Rx Issue Datebull I I I I I I I I M 0

Rx Expiration Date I I I I I I I I yM M 0 0

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Absent a valid med1cal reas n the prescnption cannot exp1re less tnan one year after the ISSue date in any state (or in stategt that permit

longer prescnption lengths ln prescription cannot expire before the date specifed oy the state) If tne preswber ha$ a valid medical reason

for dev1atmg from tle default rescnpt1on lengtl under state law at the tlme the pescnpton was ISSued we ask that the medical J~dgment be

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bear Eye Care Provi e

We are requesting tt contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consuf rs Act (Public Law 108-164) which requires the prescrlber to provide a copy of

the contact lens pre~c iption to any person designated to act on behalf of th~patient This customer

has authorized 1-809 ONTACTS to request this information on hish~r behalf This is not a contact lens

order verification req est

Pl~ase either (A) ~enb s a copy of the customers actual prescription or-alternatively WJ complete and I middot~ bull

send back to us the rscription Form below including all parameters applicable dates and signature middot

The actual prescriptio or Prescription Form should be sent to our toll~free fax number 1-888-407-2020 I


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Power Base Curve Diameter CyiAdd middot OD

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t e date on which the patent receives a copy of the prescription at the completion of their contact lens fitting

s n the prescriotion cannot CKO bullc Jess than one year after the issue date in any state or in states that permit

h pescription cannot exoire -before the date specified by the state) If the prescriber has a valid medical reason

t reitriotion length under state taw at the tine the prescrlpfon was issred we ask that the medical judgment be

te that this informafion may Oe provided to the ~ltltient

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Exam Date

Rx Issue Datebull

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bullAbsent a va lid medical re longer prescri ption lengths

fordeviatingfrom the defa documented and attached

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RFS-02 Fax Server

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middotDea Eye Care Provi_ bull

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We are requesting t~e c~ntact lens prescfiptqri fort~~ following~custonier pursu~nt to th~ Fairness to Contact Lens Consum rs l)ct (Public Law 108~164) which requires the prescriber to provide a copy of

the contact lens preJcmiddot iption to any person design~ted to act on behalf of the patient This custoer I bull bull bull middot

has authorized 1~80 ONlACTS to requestthfs informationon hisher behalf This is not-acontacflens o~derverification re ~~~-~ - - middot

middotmiddot middot- ) middotmiddotmiddot~- - - middot-~middot~ - - (

Please either (A) sen )1s a copy of the cust(mei-s actual prescription or alternatiyely (B)compl~te and

middot middot send back to us the r scription Forril bela_ inciud[ng alLparaineteis a~plicabledates and signature -~ gt_ -~(jbull middotmiddot _middotgtmiddot~-middot~--_~middotmiddot1~~- --~~-~gt-~_ - middot __-_ -

The actual prescripti middot oiPrescriptionForm shouldbe sent to bur tciHree fax number 1888-407-2020bull

by osj1420~s Pie ~ return this for~-ev~h ifiJe pp(am~tesbeiware correct bull cj bull bull - bullr --middotmiddot bull~ bull (

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~~~t ~-1 f _ shy - gt bull _ f bull ~ - - - - bull bullbull middot_ - bull

bullThe term Rx Issue Date~ i t e date on whch the pat~ent reCeives a copy oftheprscrlption at thecompletion oftheir-contactlens fitting

- middot _middot - _ gt- - ~ bullbullAbsent a valid medical re s the prescril)tion cannt exp~middote leSs than one ybull1ar arter thebulli~~_ue date in any state (or in states that permit lOnger ~resCrfptioniEiJgths h1~pre~middotCriPtron dtn~otemiy b~fore the_date specifed_ bVt~emiddot ~t~te) lftile prescriberhltis avilid meical reason

1 tor deviating tr6rn the defau tl rescriPtion engthund~(stat~ 1iw ai ~e tirne the_pnscriptio~_waS issued we ask thatmiddot the m~dical judg~ent be

1documented and attached te thafthismiddotintolmation riiclr oe provided to tlie latfe1t

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We are requesting t~e ontact lens prescription for the (ollowing ~ustomer pursuanttothe Fairpessto middotContact Lens Consu1e s Act (Public Law 108-164) which requires the prescriber to provide a copy of

middotthe contactlens presp ption to any person designated to act on b~halfof the patientmiddot This customer

has authorized 1-800 ONTACTS to request this information on hisher behalf This is nota contact lens

order verific~tion reJu -~t ~ middot middot ~- _ middot middotmiddot middot middotmiddot - - middot _ middot II - middot

Please either (A) send s a copy of the customers actual prescription or alternatively (B) complete and

send back to us the 9r ~cription Forin bel~w including all ~a~ameteis applicable middotdates_and signature

The acual prescripf ~r Presci~iltin ~arm s~ld b~ ~e~t-to~~~ i~i1-fr~e fax number~middot888-40~-202~I

by OS142015 ~lermiddot ~eturn this fo e~en if tile p~ra~~er~ bel~~ are ~orrect

Patient Name Address middot

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bullbull middot- ~ BrandMa ~ acturer Power Bamiddotsecurve ~ middotmiddotmiddotDiameter OilAdd Axis

OD r Acuvue ols s24pk I -37s _ I 84o~middot middot bull 1- 14omiddotmiddot I ooo I

OS r Acuvue o1svs i4pk I middot-375 middot I 84o 1140 I ooo Io I Exam Date 1 I I I I I

M Y y middotD ~-- M _ bull J Imiddot bull 1- bullI _ middotmiddot1 middotmiddot ~~--I _ I bull I I I I

D y yM M D y y - middot

Rx Expiration Date I - I T I I I I M y y y yD

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- middot bull7The term ~RK Issue Date i t e dat~ on whi~h the patient receuro[ves a ~opy of ttie pr~scriptio0middotat the completion of their contact lens fitting

middot

bullbullAbsent a valid medicltl re inthc prescriptioncan~~tcK~fre (e~ th~n on y~ar after ~emiddotiS~e date in any state orin states that permit longer prescription leniths th Prescription cinnoteXpirebefore th~ date speCified by the State) lfthe prescriber has a valid medical reason

for deviatiilgfrom the defabull I~ rescription length undei state law at theti~e the prescriptlon was issued we ask that the ~edical judgment be

do_cumented and attached Ntethatthis informatio maymiddotbe proVided to the aiient~

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~ RFS-03 572015 114234 PM PAGE 1001 Fax Server

Dear Eye Care Provid r ~ ~~gt ~middot middot~--~ We are requesting th ontact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consurre s Act (Public Law lOS-164) hich requires the prescriber to provide a copy of

the contact lens pres~r ption to any person d~signated to act on b~half of the patient This customer

has authorized 1-8oolcbNTACTS to request this information on hisher behalf This is not a contact lens

order verification reqL st middot

Please either (A) send sa copy of the customers actual prescription or alternatively (B) complete and

send back to us the Pr cription Form below including all parameers applicable dates and signature

The actual prescription or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 1

by 05142015 Plear return this for~ even if the parametersbelow are correct

IPatient Name Address ~-~

00

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~ BrandManu

r middotmiddotsiomedlcsmiddot

f Biomedicsmiddot

cturer

6pk

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I -275

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I 85o

1 850

Diameter

I 142middotmiddot

1142

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lo

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M middot

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bullrhe teem R e Dote Jh date on whloh the potlent ceoeles a ropy of the pcescrlptlon at the oompletloo of thelc oon~ct lens fitting

Absent a valid medical reaL the prescription cannot expire less than one year after the issuedate in any state (or in states that permit

longer prescription lengths f presc~iption cannot expire before t~e date specited by ~he state) If the prescriber has a valid ~e-~icat reason

for deviating from the default rescripti_on length under state lawmiddotat the time the preSCfiption was issued we ask that the med1cal Judgment be

~ocumented and attached ~o e that this informatiOl may be provided to the patient

1359775

RFS-03 572015 111424 PM Fax Servermiddot

Oear Eye Care Provid r

We are requesting the ontact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consumk Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pres+ lion to any person designated to act on behalf of the patient This customer

has authorized 1-800 C NTACT~ to request this information on hisher behalf This is not a contact lens

order verification req~E st I

Please either (A) send u a copy of the customers actual prescription or alternatively (B) complete and middot

The actual prescriptio or Prescription Form should be sent to our toll-free fax number 1-888-407-2020

by 05142015 Plea e return this form even if the parameters below are correct middot _ middot

I Patient Name Address

BrandManuf cturer Power Base Curve Diameter cvliidd Axis

00 f I I I _ I I I I I

OS r AcuvueO~ forAstig6pk1-375 1 860 1145 I-12s 1180 I

Exam Date

I

M

M

1

I

M

M

l

I

D

D

1

I

6

D

-I

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bull y

y

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~T~~~te lsj da~e on which the ~ti~nt receives acopy of the prescription

~i the completion of their contact lens fitting bullbullAbsent a valid medical reas n the prescription cannot cxp~re less than one year after the issue date in any state or in states that permit

longer prescription lengths t e rescription cannot expie before the date specified by the state) If the prescriber has a Valid medicai reason

for deviating from the default pr scription length under _state law at the time the prescription was issued we ask that the medicaljudgment be

documented and attached N t that this information may be pfovided to the patient

1359465

-~middotmiddot RFS-03 5172015 104201 PM lAGf 1001 Fax Server

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Dear Eye care Provid r

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Contact Lens Consumfr Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens presc(i yon to any person designated to act on behalf of the patient This customer

has authorized 1-800 C NTAcrs to request this information on hisher behalf This is nota contact lens order verification req~ st middot

Please either (A) sen)u a copy of the customers actual prescripton or alternatively (B) complete and

send back to us the PfJe cription Form belowmiddot including all parameter~f~licable dates andsignature

The actual prescriptio br Prescription Form should be sent to _our toll-free fax null]ber 1-888-407-2020

by 05142015 Plea e return this form even if the parameters below are correct


~ Bra-ndManuf cturer Power Base GurVe Diameter CyiAdd Axis

OD r Acuvue Oas~ 6pk 1 -800 1840 1140 Iooo lo I 1 bull

as I I I I I l I I

Exam Date II I I I I I I I I y y yM D D

I 1 1 1 I I I I y yM D D y y

Rx Expiration Date I 1 1 1 I I I I y y y yM D D

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Doctors Signature --++----------------1~fl~-~-----~--

The term Rx Issue Datemiddot is t e dat_e on which the paten_t reCeives a copy Of the presCription at the completion of their contact lengt fitting

Absent a valid medical reas n the preCription cannot expire Jess than one year after the issue date in any state (or in states that permit

longer prescription lengths t e rescription cannot eXpire before the date specifed by the ~tate) If the prescriber has a vali~ medical reason

fo~ deviating fromthe default pr scription length Under state law at the time the p~escription was issued we ask that the medical judgment be

documented and attache~ N t that this information m_iiy be provided to the gtatient ~

1359028

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RFS-01 572015 10 (07 25 PM PAGE 1001 Fax Server ~

middot

bull Dear Eyemiddot Care Probullviderl

qo1ntact lens prescription for the following customer pursuant to the Fairnlssto

Contact Lens IUIIlgturn~bullrp Act (Public Law 108-i64) which requires the prescriber to provide a copy Of

oregtsclmiddotibtion to any person designated to act on behalf of the patient This customer

rmTAr-rc to request this information on hisher behalf This isnot a contactl~ns

middot~uiJ~ a copy of the custome(s actual prescription or alternatively (B) complete and

p(bullltnmiddotlntlnn Form below including all parameters applicable dates and signature

precriptioh l~r Pres~ription Form should be middot~ent to our toll-free fax nurnber 1-888-407-2020

form even if the parameters below are correct

Patient Name bullbullbullbulla Address

OD

OS

Exam Date

Rx Issue Date

Rx Expiration Date

I

M

M

M D D y y y y

Doctors Signature --++-----~--------OC--~--------

4~~gt- The term Rx Issue Date is on whch the pj~lt_ receives a copy of the prescription at the compieton of their contact tens fitting

~

the prescription can riot eKpfe less than one year after theissue date in any state (or in states that permit jrecrlption cannot eKpire 9efore the date specified by the state) If the prescriber ~as a valid medical reason

fordebulllating frongtthe dbullbullfocbullltJprbsoriptlonlength unde~~ate law at the time the prescription waS isslled we ask thltit the medical judgment be this informatiOn may be provided to the patient

1358565

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IIRFS-0 2 5172015 100310 PM PAGE 1001 Fax Server

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We are requesting thl ontact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consumes Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pres~r ption to any person designated to act on behalf of the patie~i Thicustomer

has authorized 1middot800C JNTACTS to request this informati~n on hisher behalf This is not a contact le~s order verification requ st I middot -middot Please either (Al sen1( sa copy of the custo~ers actual prescript ion or alte~natively(B) complete and send back to us the P e cription Form below including all parameters applicable dates and signature The actual prescription or Prescription Form should be sent to our toll-free fax number l-888-407middot2020

by 05142015 Plea~e return this form ~ven if the parameters below are correct

I middot I If

Patient Name ~--~~~~ Address bullbull

Power Base Curve Diameter CVIAdd middot Axis~l_OD I

I -47s I 83o I 14o looo lo I

OS I Acuvue 2middot(6p ) 1 830 1 140 Iooo middotI o I middot

Exam Date

Rx Issue Date

I M

I

I

I

M

1

I

0

1

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Rx Expiration Date I M

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Doctors Signature --J-1-----------------------shy

-~-~ middotmiddot- ~ ~ The term Rx Issue Date is t edate on which the patient receives a copy of the prescription at the completion of their contact ~nsfitting

Absent a valid medical reas n the prescriotion cannot elpre less than one ye-ar after the issue date in any state or in statesthat permit

longer prescription lengths t e rescription cannot expite before the date specified by the state) If the prescriber has a valid medical reason

for deviating from the default pr scription length under state Jaw at the time the p~escription was issued we ask that the medical judgment be

documented and attached N t that this informatiol may be provided to the Jatient

1358507

RFS-03 572015 9 (51 07 PM PAGE 1001 Fax SElrver

middot

Dear Eye Care Pravidell

Contact Lens

We are rec1uesti11glth~ ltjo1ntact lens prescripti~nfor the following c~stomer pursuant to the Fairness to

Act (Public Law 108164) which requires the prescljber to provide a copy of

ore~scimiddotibtion to any person designated to acton behalf of the patient This customer

has authorized 1-800(q1NlACTS to requestthis information on hisher behalf This is not a contact lens

order verification recJi)E~t

Please either (A) send a copy of the customers actual prescription or alternatively (B) complete and

send back to us the Form below including all Parameters applicable dates and signature

Prescription Form should be sent to our toll-free fax number 1-888-407-2020 --

by 05142015 Pleatwmiddotn this form even if theparanieters below are correct middotmiddot middot bullbull ~ middot bull

middot Patient Name Address

OD

OS

Exam Date

Rx Expiration Date

M

bull- )_

Theterm uRx Issue Date stJdclate on which the patien acopy of the prescription at the comptetion of their contact lens fi~ng

bullbullAbsent a valid medical the prescriPtion cannot exP1re)ess than one year after theissue date in any tate or in states that permit

middot

longer prescription lengths presorptoncannot~iltptre befor~ the date Specified by the state) If the prescriber has avalid medical reason

for deviating from the de~altJptgtSorptgtn length under statemiddotlaw atthe time the presciiptiOn was issued we ask that the medical judgment be middot documented and attached that this informatiol may be provided to the ~atilnt

1358338

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RFS-03 517201591826 PM PAGE 100i Fax Server

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1800 middotcontactsmiddot middotDear Eye care Provilter middot middot _ middot

We a re reqesting t~middot contact lens pr~~~riptio~ forth~_~oil~~-ing _uso~~r p~rsuani to the Fairness to Contact Lens Consu rs Act (Public Law 108-164) which requires the prescriber to provide a copy of the contact lens pre t iptionmiddotto any perso~ design~ted to a~on behalf of the patient bull This custorii~r has authorized i8oi middotONTACTS to request his information on hisher behalf This is not a contact lens order verification re~ est

Please either (A se+ us a copy of themiddotcs~orn~rs actual pr~scriPtion or alternativeiy (B) complete and

send back to usthe _] r~scriptio Form below hidudirg all paameters applica~le dat~s ~nd si~n~ture

The actual prescriptio or Prescription Form should be sent to our toll-free fax number 1-888middot407-2020

by 05142015 Ple~s return this form even if the parameters below are correct _ bull

1 - il bull bull 1

Patient Name ~middotmiddotmiddotmiddotbullbullbull Address

-bull

middot OD

bull -i middot

BrlndMan Uacturer

I BiofinitV 6

bull

Power-

middot I middot37s

-

Base Curve

I s6o

Diameter

I 14o CyiAdd

I ooo Axis

Ia I

bull 0OS I Biofinity 6b Ids middot middotI s6o 1140 Iooo lo I

bullmiddot

Exam Date I I I I I I I J M M 0 0 y y y y

Rx Issue Date

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Rx Expiration Date I I I I r I I I

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Doctors Signature -+-f------~--------~~------- bull

- _- The term Rx Issue IJate is date on which the pat-ient-receives amiddot copy of the prescriPtion at the compl_etion of their contact lens fi~ting

bullbullAbsent a valid medical rea o ~e prescriptior~ caOnOt exp~remiddott~s~ than oneviar after the issue daie in any state or in states that permit

longer prescription lengths t eprescription cannot eKpire beformiddote thmiddote date specified by the state) lfthe prescriber has a valid medical reason

for deviating fro~ ihe defaul p escription length under stale law at the time the prescr1~tion vas issued we ask that the medical judgment be

documented and~ttached o ~that this ~nformation maybe proVided io the Jti~ili bullmiddot _ - 1357887

bull

middot



We are requesting tfl contact lens prescription for the following customer pursuant to the Fakness to

Contact Lens Consu rs Act (Public Law 108-164) which requires the prescriber to provjpe a copy of

the contact lens pre c iption to any person designated to act on behalf of the patient Thl~middotcustomerI has authorized 1-800 ONTACTS to request this information on hisher behalf This is not a contact lens

order verification reb est

Please either (A) se~~ us a copy of the customers actual prescription or alternatively (B) c~mplete and

send back to us the~ escription Form below including all parameters applicable dates and signature

The actual prescriptlo or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 by 05052015 Plei e return this form even if the parameters below are correct middot

middot

Patient Name~~------- Address

BrandM ufacturer Power Base Curve Diameter CylAdd

OD Soflens ~8 pk -700 870 140 000

OS Soflens j8 pk -425 870 140 000

Exam Date

M

Rx Issue Date

M

Rx Expiration Date

M M D

Doctors Signature +-11-------------------------shy

The term Rx Issue Date i the date on which the patent receives a copy of the prescription at the completion of their contact lens fitting

bullAbsent a valid medical e son the prescription cannot ~xpre less than one year after the issue date in any state or in sUites that permit

longer prescription lengt~s the prescription cannot expire before the date specifed by the state) If the prescriber has avalid medical reason

for deviating from the dera It prescription length under state law at the time the prescripton was issued we ask that the medical judgment be

documented and attached Note that this informatio~ may gte gtrovided to the gtatient

1246328

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documented and


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1800 contactsmiddot

middot~middotwe (eciuesti11rl themiddot contact lens prescription for tlie folloWing customer pursuant to the _Fairness to bull -4

Act (Public Law 108-164) which requires the prescriber to provide a copy of niFbullkrrmiddotintinn to anyperson designated to act on behalf of the patient This customer

bullhas authorized CONTAcrs torequest this information on hisher behalf This is not a contact l~ns middot ~rder verific~ii6n (e1ust

ltigtrirlolaquo a copy of the customers actual prescription or alternatively (B) complete and PrFbullltromiddotintinn Form below including all parameters applicable dates and signature

nmiddotltfnn or Prescription Form should be sent to our toll-free fax number 1-888-407-2020 return this form even if the parameters below are correct

l )~-f~~~~tdjmiddot ~- -

OD

OS

M M 0 0

Rx ISsue Datebull M M D 0

Rx Expiration Date

M M 0 0

Doctors Signature J--1~----------------------- middot

bull bullbull middotmiddot1 middot-~r b bull bull bull

the date on whichth~-~ti~rit receiVes middota cOpy ofthe prescrlPton at the completion of their contact lens fitting

bullbullAbsent a valid modlbulldrcbullpscgtn the prescription cannot expire Jess than one year after the issue date in any state (or in states that permit lonl~~sltht prescription cannot expire before the datespecified by the state) If the prescriber has a valid medical reason

dojajltpres_ptlonlenitl und~r State law at the time the prescription was issued we ask that the medical judgment be Note that this information may be provided to the patient

1418462


Dear Eye Care Providr

We are requesting the ontact lens prescription for the following customer pursuant to the Fairness tQ

Contact Lens Consum~ Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pres9~iption to any person designated to act on behalf of the patient This customer

has authorized 1-800 C NTACTS to request this information on hisher behalf This is not a contact lens

order verification req~ st

bullmiddot Please either (A) send sa copy of the custom~rs actual prescription or alternatively (B)omplete and

send back to us the Pfe cription Form below including all parameters applicable dates and signature

The actual prescriptidn or Prescription Form should be sentto our toll-free fax number 1-888-407-2020

by 05142015 Pleate return this form even if the parameters below are correct

Patient Name Address+lo-bullbullliiiL

BrandManu cturer Power Base Curve Diameter CyiAdd Axis

OD I PurevisianG k I -22s I s6o I 14o ]ooo lo

OS I Purevisior~ 6 k I -2so I s60 I 14o I ooo lo

Exam Date I I I I I I M 0 0

I I I I I I I M 0 D

Rx Expiration Date I I I I I I I I M M 0 0

Doctors Signature -1-+-----------------------shy

The term Rx Issue Date ilt e date on which the patent receives a copy of the prescription at the completion ofthe1r contact lens fitting

~Absent a valid med1cal re s n the prescnotion cannot ClO re less than one year after the issue date in any state or m states that perm1t

longer prescription lengthsn prescnption cannotexptre before tne date spectfied by the state) If the prescriber has a valid med1cal reason

fordeviat1ng from the defaJit rescnpt1on length under state law at the time the pescription was issued we ask that the medical judgment bedocumented and attached N te that this information may be provided to the patlent

1357306 bull

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We are requesting t~e ontact lens prescriptionmiddot for the follciwingcustomer pursuant to the Fairness to

Contact Lens Consu~e s Act (Public Law 108-164)which r~quires the prescriber to pro~idea copymiddotof

middotthe contact lens presh ~tio~ to any person designated to act oi behalf of the patient This custo~er 1

hmiddota_s a_uthcgtrized 1~800 ONTACTS to request ths informationon- his-her behalf This isnot acontact lens order verification re u st -

Please either(A) sendmiddot sa ~~py of the cust~mer~ actual prescription-or alternatively (B) complete and

send b~ck to us th~ t ~~jption For~ b~loY including ~lmiddotpaame~er~ applicable dats and si~nature The_ actual prescripti1~ or Prescription Fornishouldmiddotbe sent to our toll-free fax hu~ber 1-888-407-2020

by 05142015 Pleas return this formeven if the parameiers below_are correct middot middot middot

middot middot~ -

I

I I I - I

I -

I Patient Nanie i+-bullbullbullbullbull Address bullbullbullbullbullbullbullI

middot~-middotmiddot--shy_middotmiddot middot

Power BaemiddotJ~~~ middotofa~eter middot CVIAdd1 ~middot Axis OD middot I BioflnityT6r1 6pk I 4so middotmiddot J s7Q bullmiddot h45 I 075 1150 I middotI middot as I BiofinrJri middot 6pk I 450 middot I s1o 1145 l-o75 l2o I

Ii middot ~~~middot 1-Exam Date I I middot_ I I I I I J

M M 0 D bull Y y y - y middot

I y

Rx Expiration Oat~ I y y y yM 1 0 0

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Doctors Signaturemiddot-+t---------------------7-------- shy ~- middot bull

The terr~ ulx)Ssue DateiS h da~e on which the patre~n~_receiv~~ a copy~~f the prescriP_tio~middotmiddotat th~_conPietion ~fthei~ ~rit~ct enstitting ~ bull - - lt l bull bull middot bull bull bull L

~Absent a valid medica-rea o the prescrition ~nnot ex~rc ~~~sthan rrc y~arart_er t~~ issue date in ciny state or in statesthat permit Ion~~ pr~cription lengt~~ t1emiddot _middotr~_crlption can~t~xPfre be~re the datespe~ifid by ihi stae)middot rtthe prescriber ias_ aValid medical reason for deviating from the defaul pescmiddotription length under state JaW at the timetie prescription Was issJed we ask that th~ medical judgment be middot documented andattached o that this information m3yOe provided to the oatlerlt - -~ -

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1800 contacts~middot -

-lt 1 bull -

middotDear Eye care Pra~Jdf _ _- middot - _ middot middot middot

We are reque~ting t~~ co~tact lens prescription fomiddotr he ~llowing cu~tomer pursuant to the Fairness to Contact Lens Con~u1 rs Act (P~blic Law 108-164) which requhes the ~rescriber toprovide a copy of

the contact lens presc iption to any person designated to act on behalf ofthe patient This customer

has authorized 1-8od ONTAcTS to request this information on hisher behalf This is nota contact lens I bull bullbull

order venficallon request middot middot middot middot - middotPl~ase either (A) s~n~ sa c~py of t~ec~st~ers actual [escipt~ or alternatively middotB) ~omplet and

sen~backtci us ther_sc~i~tio~ For~ below includjng all p~r~~et~r~ applicable dates and ~ignature

The actual prescriptip or Pr~scri~tion F~r~ -~houldmiddotbe s_ent tomiddot9ur toll-free fax number 1-888-407-2020

by 05142015 Ple~s return thos form even of the parametersbelow are correct middot middot 1 shy

bull

tPower Base Ci~rvf olarrieter middot CVIAdd Axis

I s1o I 14o Iooo lo I lmiddot ~ ~ ~-

os I Acuwe A~~ ncej6pk) I -3ls 1 bo middotI 14o Iooo lo I middot-middot bull

I EX~m Date I y yM M middot- ~middot D

I I Rx Issue Qatebull I I _ middot I I

D y v yM bull

middotI I I I Rx Expiration Date J I I middotmiddot I M M D D y y y Y bull

I I

Dodor-s Signature _1+middot-f--------~~--~----~--~-~-----

r J~ bull bull bull c

The term Rx IsSue Date s he date On ~VhiCh tlu patient reteives a capy Of themiddot pfe5cripio)i at the completion of their contaCt lens fittit1g ~ middot ~ -

bullbullAbsent a v_al_i~ medical r a o~ the prescription calrot eilpre less than one ye~r after the iss~e date in any_ state or in states that permit

_longer prescription lengthSJf ~ pres~fiption cannot e~pir~ bef9rethe dtespe~ifie~ bv~e s~te) bull lfthe prescriber has a valid 111edical reason for deviating frOm the middotqer Ul prescription JengthmiddotuOde~ state laW at t~e~ime tlie_piesCription wasissued we ask ~at the medical judgment be

documented and attached ote that this informatio1 may be provided to the lt~tiEnt ~- - middot

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1800 contactsmiddot Dear Eye care Provide

We are equesting thb ontact lens prescription for the following customer pursuant io the Fairness to

Contact Lens Consu~e s Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens preslr ption to any person designated to act on behalf of the pat1ent Th1s customer

middot has authorized 1-8od ONTACTS to request this information onhisher behalf This is not a contact lens

) bullI ii~-r~erverification reu sL _

1 middot middotPlease eithei (A) send sa copy of the customers actual prescription or alternatively (B) complete and I

send back to us the rscription Form below including all parameters applicable dates and signature

The actual prescriptip or Prescription Form should be sent to our toll-free fax number 1-888-407-2020


I I I Patient Name Address

BrandMan u acturer Power Base Curve Diameter OilAdd Axis

bull - ~middot

middotmiddot 1

OD middotl Preclear 1l D y Multifocal30pk I middot425 I 87o I 142 Iooo lo I I

OS I Procle~r lJ D y Multifocal30pk I -425 I 87o I 142 Iooo lo I

Exam Date

Rx Issue batebull

Rx Expiration Date

bull

Doctors Signature

I I I I I I I I M M D D y y y y

I I I I I I I I M Mmiddot D D y y y y

I I I I I I I I M M D 0 y y y y

The term Rx le Date l he date on which the patient receives a copy of the prescription at the completion of their contact lens fitting

Absenta vaHd medical fbull on the prescription cannot expire less than one year after the issue date in any state or in states that permit

longer prescription length e p-rescription cannot eKpire before the date specified by the state) If the prescriber has avalid medical reason

for deviating from the detJur prescription length under state law at the time the prescription was issued we ask that the medica judgment be documented and attached ote that this information may be provided to the patient

1425261

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bull


1800 contactsmiddot Dear Eye care Provia r

I We are requesting tr contact lens prescription for the following customer pursuant to the Fairness to

Contact Lens Consur rs Act (Public Law 108-164) which requires the prescriber to provide a copy of

the contact lens pres ription to any person designated to act on behalf of the patient This customer I

has authonzed 1-800 CONTACTS to request this information on hisher behalf This is not a contact lens est - order verification rJq

Please either (A) sel us a copy of the customers actual prescription or alternatively (B) complete and

send back to us the P esiription Form below including all parameters applicable dates and signature middot

The actual prescript n or Prescription Formshould be sent to our toll-free fax number 1-888-407-2020

by 05212015 Pitmiddot e return this for even if the parameters bel~w are correct

I

AddressPatient Name

BrandMan facturer Power Base CurVe Diameter CyiAdd Axis

OD I Biomedrds C6pk I -5oo I 85o I 142 I ooo lo I I

OS I Biomedids C6pk I -5so I 85o I 142 I ooo lo I

Exam Date I I I I I I I I

y y yM M D D y

-Rx Issue Datebull I I I I I I I I

yM M D D y y y

Rx Expiration Date I I I I I I I I y y yM M D D -

Doctors Signature

bullThe term Rx Issue Date s e d~te on which the patient receives a cqpy of the prescription at ihe completion of their contact lens fitting

Absent a valid medical r a s n the prescription cannot expire less than one year afterthe isSue date in any state or in states that permit

longer prescription lengths t e prescription cannot expire before the date specified by the state) lfthe prescriber has avalid medical re~son

for deviating from the defa I prescription length under state law at the timE the prescripti~n was issued we ask that the medical judgment be


1428726

514205 54532 PM PAGE middot1001 Fax ServerRFS-03

1800 contactsmiddot

~ _ bull

Dear Eye Care Pr6vi9~ middot middot

We are requesting t~e contact lens prescripiion for the following customer pursuant to the Fairness to

Conta~t Lens Con~uT rs Act (Public Law 108-164) whi~h requires the pres~riber to provid~ a copy of

the contait lens pre~c iption to any peson designated to ~ct on behalf of the patient This customer

has authori~ed 1-800 OtJTACTS to request this information on hisher behalf This is not a contact lens order verification re~ est middot middot middotmiddot middot

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longer prescription length$ _e prescription cSnnot expire before the date specified by the state) If the prescriber has a valid medical reason I - -

for deviating from the deJa~ prescription lenglli under state law at the time the prescription was issued we ask that the medical judgment be

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1423598

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longer prescriptiol lep hs the prescription cannote~pre before the ~ate specified by~e state) If the prescfiberhas a valid medical reason

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We are requestingJl e contact lens prescription for the following customer pursuant to the Fagness to

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1418374

RFS-02 5142015 121150 PM PAGE 1001 FaX Server

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We are requesting he co~tact lens pr(sqiption for the following custoner pursuantto the Fairness to middot~ - middotmiddot middot- _ - middotmiddotmiddot - Contact Lens Consuiners Act (Public Law 10S-i64L which requites the prescriber to provide amiddotcopy of

the contact lens p~E scription to any per~on designated io act on behalf of the patient This customer

middot has a_uthoii~~d 1-~c oCONTACTS to request t~is _infor~atior on hisher b~half This is notmiddot~cnact ~~~s middot _~~- middot- tl ~order verification r quest - middot middot middot

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send back to usmiddotte Prescription Form below including all para eters applicable dates and signature

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RFS- 03 3262015 100436 AM PAGE 11001 Fax Server -

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We are r~questing lh~contact lens prescription for the following customer pursuant to the Fairness to

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has authorized 1-8do CONTACTS to request this information on hisher behalf This is not a contact lens d fi middot Ior er ven 1cat1on rq est

us a copy of the customers actual prescription or alternatively (B) complete and Please either (A) se(ic

send back to us therescription Fornl b~low including all parameters applicable dates and signature

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1418476













OD ue Moist (30pk) -400 850 142 000


Exam Date

-M

Rx Issue Datebull

M M

Rx Expiration Date

M M 0 0 y y y

-middot-

Doctors Signature



1418374

















I

I




-


j











00

I


- bull


I Acuvue b sys 12pk

-middot

Power

- I -42s

Address




gt~---- I bull I-



middot -middot





1423598


yen -~ bull bull ~











-~

OS


M y y y


AxiS




Doctossgnatur bull






1418476













OD ue Moist (30pk) -400 850 142 000


Exam Date

-M

Rx Issue Datebull

M M

Rx Expiration Date

M M 0 0 y y y

-middot-

Doctors Signature



1418374

















I

I




-


yen -~ bull bull ~











-~

OS


M y y y


AxiS




Doctossgnatur bull






1418476













OD ue Moist (30pk) -400 850 142 000


Exam Date

-M

Rx Issue Datebull

M M

Rx Expiration Date

M M 0 0 y y y

-middot-

Doctors Signature



1418374

















I

I




-













OD ue Moist (30pk) -400 850 142 000


Exam Date

-M

Rx Issue Datebull

M M

Rx Expiration Date

M M 0 0 y y y

-middot-

Doctors Signature



1418374

















I

I




-

















I

I




-

Documents

1800 contacts· - Federal Trade Commission...Fax Server 1800 contacts· Dear Eye Care Pro i er, We are request in!• t e contact lens prescription for the following customer pursuant