Custom Lenses                     Date:____________________

 

 

After a careful examination of your particular visual requirements, it is my professional judgment, as your eye doctor, that so-called “impact resistant lenses” will not fulfill your particular visual requirements.  I have, therefore, prescribed other lenses for your use, which are being dispensed to you herewith.

 

I am giving you this notification in writing in accordance with the Food and Drug Administration’s Statement of Policy, Update April 1, 2003, Section 801.410 Subpart H Special Requirements for Specific  Devices.

 

 

Prescribing Doctor________________________________________________________

 

 

 

I have received and read a copy of this notification.  I understand that these lenses are not impact resistant.

 

 

 

Patient:__________________________________________________________________

 

 

Revised September 2010