New Lens Replacement/Reglazing 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

Details About Your Frame

Have we taken your measurements in this frame before? *YesNoI’m Not Sure

Frame Brand, Model & Colour (Please nclude as much information as you can, Most of them are found inside the arms and nose bridge of your frame) *Example: Ray Ban, RB6448 – 2502, Black, 52-18, 145

Can you upload pictures of your frame now? *YesI will send it later

Upload Pictures of Your Frame Here *Please include as much clear pictures as you can, including all sides and the writing on the arms and nose bridge of the frame if any

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 to dark when outside & clear when inside)Sunglasses only (Always Dark)Not Sure

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

Any Special Instructions? *Tell us anything you’d like us to know about your frame, lens replacement, mobility considerations, or any additional details you would like us to know about.

$20 Lens Replacement/Reglazing Deposit *To secure your appointment slot, a $20 deposit is required upon booking. Your full $20 deposit is 100% credited toward your new lenses. 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.