LensExpo.com 
Mail/Fax Order Form
If you wish to place an order by Mail or Fax:
Please print this form, fill in all required information
and fax to:

305-531-9703

Or Mail to:

LensExpo.com
1674 Meridian Avenue
Suite# 110
Miami Beach,
Florida 33139
USA

Name and Shipping Information Billing Information 
 (if different from shipping address)
Name:______________________________
Street:_____________________________ Address:_______________________
___________________________________
City:________________ State___ Zip______
Phone#______________________
Email Address:______________________		 Name:______________________________
Street:_____________________________ Address:_______________________
___________________________________
City:________________ State___ Zip______
Product Information and Prescription    

Circle 'Right - Left' Eye and insert the following information: 
Product Name | Description | Power/BC/Diameter | Color

Quantity: Price:
Right - Left #  $
Right - Left # $ 
Right - Left #  $ 
Right - Left #  $ 

Shipping and Handling (US Only):

  $5.95
!

Total:

   

 



Prescription Information:


I will fax a copy of my prescription to (305-531-9703)
I am an existing customer of LensExpo.com and prescription is on file.
Please retrieve my prescription from my Doctor's Office ($5.00 service charge will apply)

Name of the Doctor:_______________________
Doctor's/Office Phone No:__________________

Payment Method

Visa
Master Card
Discover
American Express
Check or Money Order (Make Payable to LensExpo.com)




Card Number:___________
Expiration Date:_________

I accept the above charge: 
______________________ 
        (Signature)

Thank you for choosing
LensExpo.com



IMPORTANT NOTICE TO BUYER

LensExpo.com. Copyright 2001-2002
All Foreign and Domestic Rights Reserved.
Use of this site constitutes acceptance
of the User Agreement and our Privacy Statement.

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