SpectOcular Monthly Attestation

SPECTOCULAR MONTHLY EYECARE PROFESSIONAL ATTESTATION

Eyecare Professional Name

E-mail

Practice / Entity

Month / Year

I certify that during the month identified above, I remained available to perform the consulting, administrative, research-support, patient-education, consent-coordination, imaging-workflow, quality-control, and record-release facilitation services described in the Eyecare Professional Agreement.

I further certify that, as applicable during this month, I performed services reasonably requested or necessary under the Agreement.

I understand and agree that my compensation is not based on, and is not intended to induce or reward, referrals, patient volume, imaging volume, study enrollment volume, or other business generated between the parties.

Typed Electronic Signature Date Notes / Services Performed This Month

Monthly attestation submitted.

Attestations are captured electronically. Keep monthly records according to your compliance/document retention policy.