VOLUNTARY CONSENT AND NON-SOLICITATION ACKNOWLEDGMENT FOR EYECARE SERVICES

By contacting Dr Paul Super I hereby acknowledge and confirm the following:

1. VOLUNTARY DECISION

I am seeking eye care services from Paul J Super, OD FAAO, Paul J Super OD PC entirely of my own free will and volition. My decision to receive these services is completely voluntary and self-initiated.

2. NO SOLICITATION

I confirm that I was NOT solicited, recruited, approached, or persuaded in any manner by the above-named provider or any representatives, employees, or agents acting on their behalf to seek or receive eyecare services. No one associated with the provider initiated contact with me for the purpose of encouraging me to become a patient or receive services.

3. INDEPENDENT DECISION

My decision to seek eyecare services from this provider was made independently and may have been based on one or more of the following:

• Personal research

•   Referral from a trusted source (not affiliated with the provider)

•   Personal recommendation from family or friends

•   Online reviews or information

•   My own initiative and need for eyecare services

4. UNDERSTANDING OF PURPOSE

I understand that this acknowledgment is being provided to confirm compliance with applicable laws and regulations regarding patient solicitation, anti-kickback statutes, and professional conduct standards.

6. TRUTHFULNESS

I affirm that the statements made in this document are true and accurate to the best of my knowledge.