Own Frame Waiver

Patient's Own Frame (POF) Agreement


Waiver of Liability for Frame Breakage


​​​​​​​Westwood & Montrose Eye Center | Dr. Jilber Fouladian


Patient Name

Date of Birth

Description of Patient's Frame (Brand/Color)

You have requested that new prescription lenses be placed into your existing eyeglass frame ("Patient's Own Frame"). While we are happy to provide this service, please be aware of the inherent risks involved in working with used eyewear.

I. Understanding the Risks

Eyeglass frames are subjected to stress, heat, and pressure during the process of removing old lenses and inserting new ones.

  • Material Fatigue: Plastic and metal frames dry out and become brittle over time. Even a high-quality frame that looks fine on the outside may have microscopic stress fractures or hidden weakness.
  • Breakage: There is always a possibility that the frame may snap, crack, or break during the laboratory process. This is often unpredictable and unavoidable with used materials.
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II. Release of Liability

Westwood & Montrose Eye Center and its laboratory staff exercise the utmost care when handling your property. However, because we cannot guarantee the structural integrity of a used frame:

We are NOT responsible for breakage or damage to your own frame during the lens insertion process. By signing this form, you release Westwood & Montrose Eye Center from any liability to replace the frame or refund the cost of the frame should it break.

III. Our Commitment to You

In the unfortunate event that your frame breaks, we will not leave you without options.

  • Replacement Assistance: We will work with you to find a suitable replacement frame from our inventory.
  • Discounted Replacement: We will offer a significant discount on the purchase of a new frame to help offset the inconvenience.
  • Lens Remake: If you purchase a new frame from us to replace the broken one, we will re-cut or re-order your lenses to fit the new frame at no additional lens cost (if possible based on lens size).

I have read and understand the policy above. I assume full risk for the use of my own frame and agree to the terms regarding breakage and replacement.​​​​​​​

Signature of Patient or Legal Guardian

Date

TEXT FOR APPT
Los Angeles (310) 234-8900 Montrose (818) 330-7555