| Fax Us Your Personal Info |
Some customers do not feel safe giving out their personal information even on a secure website. Just print this page, fill
it in completely and fax the form to us at 800-443-4950. Just enter your Rx information along with the shipping and billing
information. Then fax this form and your order will be confirmed, processed and shipped directly to you.
it in completely and fax the form to us at 800-443-4950. Just enter your Rx information along with the shipping and billing
information. Then fax this form and your order will be confirmed, processed and shipped directly to you.
FACSIMILE ORDER/BILLING FORM
DATE: _____/_____/_____
PATIENT NAME: _________________________________ EMAIL: _____________________________
ADDR: ______________________________ CITY: ______________________ ST: _____ ZIP:_________
PHONE#: ______-______-___________ D/O/B: _____/_____/_____ (mm/dd/yy)
DOCTOR INFO:
PHONE FAX
NAME: ___________________________ (______)-______-________ (______)-_____-________
(IF KNOWN)
LENS INFO: RIGHT LEFT
LENS NAME: _____________________________ _______________________________
(IF SAME AS RIGHT LEAVE BLANK)
BASE SPH
CURVE DIAMETER POWER CYL AXIS COLOR QTY
RIGHT ____.___ ____.___ ____.___ ____.____ _____ ____________ _____
LEFT ____.___ ____.___ ____.___ ____.____ _____ ____________ _____
MONEY
Credit Card: (circle one) VISA M/C AMEX DISC ORDER CHECK PAYPAL
Credit Card#: _______________________________________
Expiration Date: ______/______ (example: 02/09)
Charge Amount: $_________.______ SIGNATURE: _________________________
DATE: _____/_____/_____
PATIENT NAME: _________________________________ EMAIL: _____________________________
ADDR: ______________________________ CITY: ______________________ ST: _____ ZIP:_________
PHONE#: ______-______-___________ D/O/B: _____/_____/_____ (mm/dd/yy)
DOCTOR INFO:
PHONE FAX
NAME: ___________________________ (______)-______-________ (______)-_____-________
(IF KNOWN)
LENS INFO: RIGHT LEFT
LENS NAME: _____________________________ _______________________________
(IF SAME AS RIGHT LEAVE BLANK)
BASE SPH
CURVE DIAMETER POWER CYL AXIS COLOR QTY
RIGHT ____.___ ____.___ ____.___ ____.____ _____ ____________ _____
LEFT ____.___ ____.___ ____.___ ____.____ _____ ____________ _____
MONEY
Credit Card: (circle one) VISA M/C AMEX DISC ORDER CHECK PAYPAL
Credit Card#: _______________________________________
Expiration Date: ______/______ (example: 02/09)
Charge Amount: $_________.______ SIGNATURE: _________________________