Billiard Eyeglasses Prescription Order Form

Billiard Eyeglasses Prescription Order Form

Gordon Harrison - Dispensing Optician
My Products
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1 pair of Prescription Billiard Eyeglasses
$209.95CAD



Add Progressive Lenses
$69.95CAD



Add Anti-Reflective Coating
$49.95CAD



Add Ultra-Thin Lenses
$49.95CAD



Shipping Charge
$19.95CAD



Total

$0.00CAD
Where to send the order
Ship to Name:
Ship to Address:
Ship to City:
Ship to State/Province:
Ship to Country:
Ship to Zip/Postal Code:
Ship to Phone:
Credit Card name and address (if different from the "Ship to" info above)
Name:
Address:
City:
State/Province:
Country:
Zip/Postal Code:
Phone:
Your E-Mail: required (For order confirmation)

Rx Information - We need this to complete your order

For Progressive Lenses Please ADD the appropriate values if applicable:

Value

Progressive Lenses "ADD" ======>
Eye Doctors's Name
Eye Doctor's Phone #
IMPORTANT:

Legally, we must receive a copy of your prescription before your order can be processed. It should be written on the eye doctor's prescription pad or your optician's paperwork and MUST include the pupillary distance (IE: PD) measurement.

Please SCAN your prescription and e-mail it to coupe@bellnet.ca, or TEXT it to 1-514-830-1898.
Credit Card Information
Your Name: required (as on credit card)
IMPORTANT:

After you have completed all the information fields on this Order Form and hit the SUBMIT button, we require 3 additional pieces of information related to your Credit Card. Please E-Mail to coupe@bellnet.ca: 1) Credit Card Number, 2) Expiration Date and 3) The CVV, 3 digits on the back of the card.

Thank you for your order and attention to the webpage details.
Should be Empty:

Where to send the order