Emergency Eyewear Order Form
Please complete the form. Once the order form is completed someone from our optical shop will contact you for further information and/or payment. Orders should be shipped to your house within 3 business days of order process completion. You can contact us directly at esaopticalshop@gmail.com or 478-923-5872.
FIRST NAME *
LAST NAME *
DATE OF BIRTH *
MM
/
DD
/
YYYY
PHONE NUMBER WITH AREA CODE *
SHIPPING STREET ADDRESS *
SHIPPING CITY *
SHIPPING ZIP CODE *
PREFERRED CONTACT METHOD *
Required
GLASSES OPTIONS- IF YOU DO NOT WANT GLASSES SELECT "NONE" FOR FRAME AND LENS OPTIONS AND CONTINUE TO CONTACT LENS SECTION
Optician measurements are taken when you order glasses onsite. This is not done during your exam by your provider. Online glasses orders use average measurements. They are generally reliable estimations but in some cases will result in lens production less desirable than an in person visit. We may request a head shot image (selfies will do) to estimate these measurements or you can email one to esaopticalshop@gmail.com after you complete this form just in case we do not have the measurements to avoid delays.
Prescription - Select ONE *
Required
Select frame option- Select ONE *
LENSES FOR GLASSES - Type and Price Option - Select ONE *
Contact Lens Option- If you do not want to order contact lenses please select "NONE" for options
The form will alert us if you want to place a contact lens order. Due to the many options of contact lens brands and fits, we will contact you with pricing info for the contacts listed on your prescription.
Contact Lens Options - Select ONE *
I understand glasses and/or contact lens online ordering is our effort to provide emergency eyewear during the COVID-19 crisis. It will be made based on the prescription provided and would not necessarily be the current prescription if I were to have a new exam. *
Required
I understand that wearing glasses is generally safer than wearing contact lenses. I also understand that wearing contact lenses increases my risk of developing eye infections including COVID-19 *
Required
I also understand that an online glasses order will use average measurements if I have not purchased glasses from Eyesight Associates before. Although a generally reliable practice, I accept that it is an inexact science. *
Required
Questions or comments
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