Eyeland Optical Patient Prescription Request Form

Electronic Vision Prescription Authorization and Consent

Please complete the form below to authorize Eyeland Optical Corporation to email your vision prescription to the address you provide. By submitting this request, you are consenting to the electronic transmission of sensitive prescription information. Once your request is received, please allow up to three business days (Monday–Friday) for processing. We will email your prescription to the specified address.

If you are requesting prescriptions for multiple patients, please submit a separate form for each individual.

You may also visit our office during regular business hours to obtain a copy of your prescription in person.

If there are any issues or questions regarding your request, we will contact you by email.