New Prescription Glasses Booking

Your Information

First Name *

Middle Name

Last Name *

Email Address *

Phone Number *

Where would you like us to come to?

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Preferred Date & Time

What day do you want this visit? *

What time do you want this visit? *

Insurance

Do you have any Insurance you would like us to bill? *YesNo

Can you upload your insurance card now? *YesI will send it later

Upload Your Insurance Card Here *You can upload one or both sides

Prescription

Do you have your prescription? *I have my prescription.I will send it later.I need an eye exam first.

Upload Your Prescription Here *

No file chosen

What is your date of birth *

Lens Preference

Type of Lens *Single Vision (Distance or Reading)Progressive (No-Line Multifocal)Bifocal (With Line)Not Sure or Not Listed

Tint/Sunglasses/Transitions *Clear Lenses (No tint or colour)Transitions (Changes between dark outside & clear inside)Sunglasses only (Always Dark)Not Sure

Preferred Lens Color *Example: Grey, Black, Blue, Purple, Red, e.t.c…..

Any Special Instructions? *Tell us about specific frame styles you like, mobility considerations, or any additional details you would like us to know about.

$20 Prescription Eyeglass Deposit *To secure your appointment slot, a $20 deposit is required upon booking. Your full $20 deposit is 100% credited toward your frame purchase. If your insurance covers 100% of the cost through direct billing, your $20 deposit will be fully refunded to your card immediately after your visit.