Patient Name
*
Verify Patient Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Confirm Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Unique Credit Code
*
Requested By
*
Please Select
Optometry Office
PEC
RCM
Other
Requested By Office Name
*
Please verify that you are human
*
How did the patient contact you?
*
In office
Over the phone
How did the patient choose to redeem their credit?
*
Applied FULL amount as credit on a sale
Requested FULL amount as a check refund
Issued FULL amount as refund to patient card
Applied PARTIAL amount as credit, requested remainder as a check refund
Applied PARTIAL amount as credit, issued refund of remainder to patient card
Total value available to patient
*
Amount applied to sale as a CREDIT
*
Amount request as CHECK REFUND (to be mailed to patient)
*
Amount issued to patient as CARD REFUND
*
Send message
Should be Empty: