Even Realities G2 Order Builder

Even Realities G2 Order Builder

Viewpoint Vision Clinic has Even Realities smart eyewear samples available in office. This form helps us prepare your frame, lens, accessory, and prescription options for review. Final pricing, prescription compatibility, availability, measurements, taxes, shipping, and order submission are confirmed by our staff before purchase.
Preferred Frame
Frame color
Lens / Prescription Selection
Lens option
Lens purpose
Prescription source
Prescription upload

Cancelof
Additional Items
Would you like to add Even R1?
Ring sizing

I already know my correct size
Accessories / Add-Ons

Not sure / discuss in office
Accessory Notes
Extra services
Patient Information
Name

First NameLast Name
Zipcode
To ensure the most accurate quote when shipping
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact
Current Visit Status
Additional Questions/Details
Prescription review factors
Measurements
Shipping
Additional shipping items
Quote Builder / Pricing Summary (Order Builder)
Retail price
Estimated total
Estimated tax
Please Select
Promotional Code:
Other adjustments
Final total confirmed by staff
Note: All prices shown are estimates only and may change based on final verification, availability, and applicable taxes and shipping.
Payment / Order Acknowledgment
Acknowledgment(s)
Patient Signature
Request Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Internal Staff Use
Staff Order Notes
Internal Order Status
Staff Pricing Adjustments
Final Total Confirmed by Staff
Should be Empty:

Even Realities G2 Order Builder

Lens / Prescription Selection

Additional Items

Patient Information

Quote Builder / Pricing Summary (Order Builder)

Payment / Order Acknowledgment

Internal Staff Use