Jervey Eye Group

Now you, our patient*, can order lenses quickly and easily over the internet. To
re-order, please complete the following secure form.

If it has been more than one year since your last visit, please call our office to schedule an appointment to update your prescription.

* For existing Jervey Eye Group, P.A. patients only.

Personal Information * required field

First Name*

Last Name*

Address*

City*

State*

Zip*

Day phone

E-mail*

Date of Birth*

Last 4 digits of
Social Security #

Location last seen*
Doctor Last Seen*

Shipping Info			If different than Billing Address
Address
City
State
Zip
Prescription Info
Ordering Options
	Right Eye	Left Eye	Description
			1 Year Supply (Free Shipping)
			Duplicate My Most Recent Order
			Other (Specify Quantity for each eye) Please NOTE: If you wear disposable lenses enter the number of BOXES PER EYE, not the number of lenses.
If ordering color lenses, list your color selection here.			Color

Delivery options
			Free Shipping
			US Mail $3.00
Orders placed after 2:00PM ship on the next business day.			UPS Overnight $28.00
			Will pick up at

Comments

Payment Info
I have vision insurance coverage with: Subject to verification and eligibility.
			Credit card information required for all orders.
Credit card*
Security code from Credit card*
Card #*
Expiration*