1. Order Details Please enable JavaScript in your browser to complete this form.Account # *Contact Point *Patient Name *Order Date *Frame (PD) *Frame (A) *Frame (B) *Frame (DBL) *Frame (ED) *Frame (SEG HT) *Coating *HMCEMIMirrorTransition *BrownGreyPhoto *BrownGreyPolarized *BrownGreyG15RX Special *BRC (BlueBlock)SHMC (Super Hydrophobic)Dip CoatingLens Type *StandardPremiumExtendedVARIOOfficeLifestyleDriveMFH's *1011121314151617181920Palux Blue *CorridorDUAL-free formPhotochromicSpecial InstructionsSubmit 2. Credit Card Authorization Please enable JavaScript in your browser to complete this form.Card Number *Cardholder Name (as printed on card) *Card Types *VISA/MasterDiscoverAmexExpiry (MM/YY) *CVC (3 or 4 digits) *Billing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePayment *Full Payment per OrderRecurring Payment (Autopay Monthly)Other (Given Amount)Date of Authorization *Signature *Clear SignatureSubmit
