THE LASIK VISION INSTITUTE, LLC
NOTICE OF CANCELLATION FOR PENNSYLVANIA RESIDENTS
Pennsylvania residents may cancel their scheduled surgery at any time without any penalty or obligation. If you cancel, any payment that you made to The Lasik Vision Institute in connection with your financing the cost of your surgery will be returned to you within 15 days following of The Lasik Vision Institute’s receipt of your cancellation notice. To cancel your surgery, mail or deliver a signed and dated copy of this cancellation notice or any other written notice to The Lasik Vision Institute at the location where your surgery was scheduled to take place. I hereby cancel this transaction.
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Patient’s Signature