Employee Eyewear Order Form

Employee Eyewear Order Form

Please fill out all applicable fields on this form to place your eyewear order. Once you complete this form, it will go to Anita who will have to approve the order.
Employee Name*

First NameLast Name
Your Email
example@example.com
Date*

MonthDayYear
Date
Who is this order for? *
Is this your employee annual pair?*

YesNoOther
Current Account Balance:*
Are you ordering glasses or contacts?*

GlassesContact Lenses
Is the order screen complete for your eyewear or contact lenses order?*

YesNoOther
Payment is to be made by cash, check, CC, CareCredit, Flex Spend, or payroll deduction of at least 10% of the purchase price paid at the time of the order and a minimum payment of $10 per pay period until it is paid in full. Payment or payment arrangements are to be made BEFORE the materials leave the office. If this protocol is NOT followed, the employee may lose this benefit for at least one year and full fees will be owed for the materials. If the order is cancelled, restocking and lab fees will be owed.
How would you like to pay for this order?*

Payroll DeductionCredit CardCashCheckCareCreditOther
E-Signature: Please type your name below to indicate that you are placing this order and understand the payment requirements before taking your eyewear from the office. *

If ordering contact lenses, please complete the following fields in this section.
Contact Lens Manufacturer
Name of Contact Lenses
RX for OD:
RX for OS:
Base Curve:
How Many Boxes Do You Want to Order Per Eye?