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RGP LENS COMPANY ORDER FORM

Website: http://rgplens.com/
E-mail
: management@rgplens.com
       Voice or Fax (Toll Free)
:1-800-552-2785            

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We Accept Payments through PayPal or by money order.

Click Here to Print the Order Form OR Click Here to return to the previous page

For your convenience, you may type in your information below, and then print the form, or hit the "Submit" button below to automatically e-mail your order to us. E-mail or Fax your prescription separately.

First Name:    Middle Initial:   Last Name: 
Ship To Address: 
City:   State:   Zip Code: 
Daytime Phone Number:   Evening Phone Number:
E-Mail Address for PayPal Invoice Notification:  
Your Account Number:
(Assigned upon receipt of your first order. Please use it on subsequent orders.)
Lens Quantity: Right Lens(es):    Left Lens(es):  
(If no quantity is specified, we will assume that one lens is being ordered for each eye covered by the accompanying prescription.)
Shipping Method:  Delivery Confirmation 
Payment Method (select one):  PayPal      Money Order
Special Instructions/ Comments:
Click Here to Print the Order Form OR Click Here to return to the previous page

 

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