By giving your frame to an i2i Opticians employee for repairs or adjustments, you (herein referred to as “I”, “me”, “my”, and “patient”) agree to the statement below.

I, _____ (patient name), understand and accept that i2i Opticians will apply their knowledge and expertise in administering, soldering, re-cutting, adjusting, and/or repairing my frame and/or lenses. As explained by the agreement and/or the staff at i2i Opticians, I understand that due to the condition, age, and/or material of my frame and/or lenses, there is a risk of breakage and/or damage. While every effort will be made to carefully adjust, repair, and/or custom mount lenses to my frame, I recognize the risks involved in repairing my eyewear and I accept the responsibility for the cost of replacement should damage occur.

_____ (patient initials)     _____ (date of signing)

_____ (staff initial)

i2i Opticians is pleased to serve you and offer the best care possible.