Glasses Repairs and Adjustments

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? *

Measurement Requirements & Frame Information

Frame & Repair Details (Check all that apply) *Frame Adjustment & Alignment (Fitting, slipping, crooked frame, tight behind ears)Nose Pad ReplacementScrew Replacement / Hinge TighteningSemi-Rimless / Nylon Cord RepairMinor Frame Tune-Up & Deep CleaningOther Repair / Not Sure (Type it in)

Did you purchase these glasses from us? *Yes, I didNo, I purchased these glasses from somewhere elseI don’t remember where I purchased them from

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

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

What is your date of birth *

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

$20 Glasses Repair and Adjustment Fee *To secure your appointment slot, a $20 fee is required upon booking. If you purchase a frame or lenses during this visit, your full $20 deposit is 100% credited toward your new 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.