JEMoptical.com Order Eyeglasses online - Fax Form

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FAX Order form

Complete Fields - Print then fax to 866-616-6059

Enter Your prescription information below (* Required Entry )

 

Examination date:  *
Doctor:                    *
Doctors Phone:      *

Questions about your Eyeglass Prescription - click here

Right: (OD)

SPH * CYL AXIS  
ADD   

Left: (OS)

SPH * CYL AXIS  
ADD   

PD:  *

Special Instructions:

Name:      *
Address:  *
Address: 
City:          * 
State:        * Zip: *

Phone:      * Email: *

Visa: Mastercard: AMX: Discover:PayPal:
Credit Card#:
Security #:       Expiration Date:

Frame: *

Lens Types and Options *

Lens Type:  

Lens Color: 

Lens Material: Plastic:    Light Weight Poly:

UV Coating : YES NO

Anti-Reflective Coating: YES    NO    

 

 

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STOP Overpaying for eyeglasses. Save 50-75% on your Eyeglasses when you order online. JEMoptical.com is an industry leader in providing affordable eyeglasses online. We have been providing eyeglasses to our patients since 1988. 100% satisfaction is always guaranteed.

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