AC Lens Printed Order Form

Instructions

Print this form if you wish to order by Fax or Mail. Make sure your entries are complete and clearly legible so that your order is processed smoothly and your lenses arrive in a timely manner. Orders can be submitted by faxing to: 877-291-8154, or by mail to: AC Lens, 4265 Diplomacy Dr, Columbus, OH 43228

Name and Shipping Information
Name:___________________________________	Are you a previous customer? (Y/N):_________
Street Address:____________________________
Street Address 2:____________________________
City:______________________ State:_________	Zip:__________________
Country:__________________________
Tel(Day):__________________________	Tel(Evening):_________________________
Email:______________________________

Your Prescription:

Eye (Circle):		Item Name/Description:	Quantity:	Price:
Right   Left		__________________________________	____________	$____________
Right   Left		__________________________________	____________	$____________
Right   Left		__________________________________	____________	$____________
Right   Left		__________________________________	____________	$____________
Shipping and Handling:				$____________ ($6.95)
Tax (Ohio residents add 6.75%)				$____________
Total:				$____________

 
Prescription Information (Please check one of the following):

My current prescription is on file with AC Lens

I am faxing/mailing my prescription together with this order (Fax toll-free to 877-291-8154 or 614-921-9866)

Please obtain my current prescription from my eye doctor.

Please provide the following information if you need this service:

Name of your Doctor or Optical Dispenser:_______________________

Doctor or Dispenser Phone No:________________________________

Patient Name:_______________________

Patient Date of Birth:_______________________

Payment Methods

Visa, Mastercard, Discover, American Express, Check or Money Order (Payable to AC Lens). Please note that we do not accept checks or money orders drawn on banks outside of the United States or in foreign currencies.

Please check one of the following:

Payment by Check / Money Order (Make payable to AC Lens and mail to the above address)

Payment by Credit Card - My card information is already on file

Payment by Credit Card - My card information is as follows

Thank you for your order

Please double-check that your order is complete and legible, especially the shipping address and phone number.

Thanks again for choosing AC Lens.
http://www.aclens.com/