To Order Eyeglass Repair, Please Fill Out Your Order Below.

Enclose the printed order with your eyeglasses and parts and send the package to the address on the order.

Repair Selection

Basic Repair $19.00

Deluxe Repair $29.00

Pemier Repair $39.00

Special Instructions (Specify any additional information below)

Your Address, Phone and Email:

Full Name:
Address:
City:
State:
Zip:
 
Daytime Phone:
Evening Phone:
E-mail

 

 

Payment Information
Select the method of payment

Check    Check Number:
 

Credit Card

Credit Card Information

Name on Card:

Type:

Visa MasterCard
Number:


Expires:

Credit Card Billing Address Address
(If different than above)

Full Name:
Address:
City:
State:
Zip:

Additional Instructions
(Specify any special shipping instructions or additional information below)

Print out this page. Mail with eyeglasses and parts, insured, in protective package to:

 

Rochester Optical Manufacturing Co. & Laboratory
Attention: Repair
1260 Lyell Avenue
Rochester, NY 14606-6616