Customer information: Office will enter tracking number

We Accept Only VISA, MASTERCARD and AMERICAN EXPRESS. Please be sure to complete shipping
address on the form below and note if billing address for the charge card and
name are different. Thank you.

Visa, Mastercard, Amex
Money orders and personal checks accepted.

Return Shipping Information:

Name: ____________________________________

Address: __________________________________


Contact Phone: ______________________________

Email: ____________________________________

How would you like to recieve your quote?
___ Email     ___ Phone Call

Add Ons:

_X_ Free eyeglass repair kit    ___ Free set of replacement nosepads

Prescription Information (Optional):

Right (OD)
Left (OS)
Pupillary Distance (PD): _________

Payment Method:

Check____ Money Order ____ Credit Card Type_____

Give Credit Card info here or call 1-866-FRAME-FX

Name on Credit Card: ___________________________

Visa, Mastercard, Amex

Card Number: ________________________________

Expiration Date: ______________________________

Billing Address if different: __________________________________

City:____________________State: _______ Zip:_________

Signature: __________________________________

PLEASE NOTE:� FRAMFIXERS takes every precaution to
protect all plastic and metal eyeglass components during
repair procedures, however, we can not be responsible for
discoloration or abrasions that may occur to used parts.