Order Form

 

 

 

 

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Name:  

Credit Card Billing   Address:

 City

State  Zip 

Shipping Address:  

City, State/Province, ZIP:  

E-Mail Address:  

Phone: (if I have any questions):  

Patch#

Size    

Type

Band Length

Band width:

Quantity

 Amount
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 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 to

2 1/4 " W X 2 " H

X-Small

2 1/4"W X 2" H to

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

Small

2 1/2 “ W X 2 1/4” H

2 3/4 “ W X 2 1/2” H

Medium

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

3 " W X 2 3/4" H

Large

3 " W X 2 3/4"H

3 1/4" W X 3" H

*Convex (eye can blink) ~ Semi-Convex (can be worn under glasses/eye can blink) ~ Flat (for uses under glasses/eye can't blink)

 

Copyright © 2006, 2007,  2008,  2009, 2010 & Beyond
Eye-GraFX Custom Eye Patches

Made in U.S.A.