Eye Patch Order Form

Home Page

Name:

Credit Card Billing Address:

City

State Zip

Shipping Address:

City, State/Province, ZIP:

E-Mail Address:

Phone: (if I have any questions):

*Visa* Master Card Card Holder Card # Exp. Date /
	Total:
	Shipping/ Handling*
	Grand Total

Credit Card users fill out order form -PRINT-Then SIGN for authorization

Signature______________________________________ (Please print then sign)

I have read the disclaimer & authorize Eye-GraFx to charge my credit card for the amount above.

Fax #: 1-918-343-2718 or mail to Eye-Grafx - P.O. Box 2433 - Claremore, Ok 74018

Make checks payable to: Eye-Grafx *S&H $00-$30 = $6.00 $31 & up shipping is Free

XX-Small

2" W X 1 3/4" H

X-Small

2 1/4"W X 2" H

Small

2 1/2 “ W X 2 1/4” H

Medium

2 3/4" W X 2 1/2" H

Large

3 " W X 2 3/4"H

Above sizes are Approximate *Convex (eye can blink) ~ Semi-Convex (can be worn under glasses/eye can blink)

Flat (for uses under glasses/eye can't blink)

These are high quality eye patches with your comfort as the goal!!