Proof of DeliveryPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient's Name *FirstLastProof of Delivery *I received an eye prosthesis from Paul Tanner with Custom DME, LLC today and have been instructed how to use and care for my prosthesis.Insurance and Financial Responsiblity *I am informed of the cost of this service. I give consent to bill my health insurance provider. I am responsible for any remaining balance on the account.I, the undersigned patient / responsible party, in order to assist in the dissemination of medical and scientific knowledge, or in the improvement of medical diagnosis and treatment, authorize Custom DME, LLC, to release, publish, display, or otherwise use photographs, models and / or videotapes which are obtained in connection with my treatment. It is understood and agreed that names will not be used or in any way disclosed in connection therewith, without verbal and written consent and specified use. The products and/or services provided to you by Custom DME, LLC are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards. *I consentI declineDate / Time *DateTimeSignature *Clear SignatureEmail *Parent/Guardian NameFirstLastSubmit