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PLEASE PRINT BTF-SBF OPTICAL FORM IMPORTANT - 271 PORTER AVENUE BUFFALO NEW YORK 14201 A PAID RECEIPT MUST ACCOMPANY THIS FORM SECTION 1 - COMPLETED BY MEMBER 1. SECTION 2 - COMPLETED BY EXAMINER 7. Charge for Exam o Signature of Examiner YES PREVIOUSLY USED BTF/SBF OPTICAL PLAN Doctor Plea.e Check 8. Type of Exam NO AN ITEMIZED PAID RECEIPT MUST ACCOMPANY THIS FORM 10. Lenses Dispensed Charge for 1st Pair Charge for 2nd Pair 12. Members Name FIR.

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