Kit Order Form

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Eye Patch Main Menu!

PayPal, Visa, MasterCard, Discover Accepted! Sorry no American Express

Eye Patch Order Form

Use Tab to advance to each field * Required fields

Please enter your Billing address below:

*Name:

Ship to Name (if different from above):

*Shipping Address :

*City: *State:

*Zip: Country:

*E-mail: Phone:

Shipping Address if different than billing address: Please fill out below:

Ship to Name:

Shipping Address :

City: State:

Zip: Country:

Band Length

Band

Width

Stud Color

Quantity

Amount

1st Class, U.S.A. & International Shipping		(U.S.A. Customers can also ship) Priority and Overnight
$00-$30 = $6.00	$31 & up shipping is Free	Priority $12.00	Overnight $24.00
Free shipping on all U.S. Priority Mail orders over $100.00

Shipping

Grand Total

For For PayPal, and Discover cards, Please use red box below

Card Holder

Example: John Doe

Card #

Example: 1111 2222 3333 4444

Exp. Date /

Enter your CVV number

(the card code is the last 3 digit numbers on the back of your card)

CVV number is located here!

To Invoice your email account for PayPal, or Discover Card!

We no longer accept American Express!

(An invoice will be generaled and sent to you email for your approval and payment. You will at that time pay for your order!)

*How to use PayPal: Click Herel

(You do not have to be a member to pay with MasterCard, Visa, Amercan Express, and Discover Cards)

Your order will not be processed until the payment has been received!

Please Write any Special Instructions Here:

Please double check and see all the information is correct on order form before submitting the order!

Remember bigger is better. We make orders per your request. We do not know if the patch size, band length, or any other portion of the order is incorrect. The elastic can be adjusted to fit your head! By clicking Submit, you agree to Eye-GrafX return/refund policy.

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+ China and other countries not listed please contact us for mail quote!

Open Monday thru Friday - 9:00 a.m. until 1:00 p.m. ~ 2:30 p.m. until 4:00 p.m. CST...

For questions about our patches, measuring or other comments, please call us at 1-918-740-9853! FAX number is: (918) 343-2718

In order to keep our prices down and order errors to a minimum, we DO NOT take orders over the phone!

Thank you for your business

We're keeping an eye out for our customers!

For your protection we maintain our website per PCI Compliance and SSL secured!