Glasses Prescription Request Form

Glasses Prescription Request Form

Please fill out this form to request your glasses prescription. We will process your request securely and send your prescription details directly to you. ** If the information submitted does not match what we have on file currently, we will not be able to process your request.**
Patients Full Name*

First NameLast Name
Patients Date of Birth

MonthDayYear
Patients legal represtative or parent:

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
MailSecure emailSecure text messageIn-office pick-up
Columbus 555 S. 18th St Suite 4C Columbus, Ohio 43205Dublin 5665 Venture Dr. Suite 1C Dublin, Ohio 43017Westerville 433 N Cleveland Ave Suite 2E Westerville, Ohio 43082
Date of Last Eye Exam

MonthDayYear
I consent to the processing of my personal data for the purpose of prescription retrieval and communication.I agree to receive my prescription details via email or mail.I am the patient listed above, or the parent/legal guardian of the patient
Signature*

Clear
By submitting this request, I understand this form will be transmitted securely to Pediatric Ophthalmology Associates, Inc. and that my prescription will only be released in compliance with HIPAA and applicable state and federal regulations.
Name of Patient/Parent/Guardian Signing
Please allow up to 3 business days to process your request.
Should be Empty: