Purchase Form

Macular Degeneration
The Path to Understanding and Overcoming

You may order by phone or print out and complete this form. Then mail with your check, money order or credit card information for $28.95 per DVD movie ordered and mail to:

The Low Vision Centers of Indiana
Drs. Windsor, Ford and Windsor
315 Huggins Drive  P.O. Box 166
Hartford City, IN 47348


Phone (765) 348-2020
Fax (765) 340-2503

info@eyeassociates.com

You will receive a complete refund of the cost of the movie and shipping, if you are or become a patient of our practice in the next 24 months.

 

 Name
 
 
 Address
 
 
 Address
 
 
 City, State, Zip
 
 
 Email
 
 
 Re-enter Email
 
 
 Phone
 
 
 Website
 
 
 # of Movies Ordered =  #         X    28.95  = total  $
 [  ] Check    [  ] Money Order   Amount of payment    $
 [  ] Credit Card  Card #
 Circle AM  Dis  Visa MC Expiration Date
Verification-Code from Credit Card (See below)  
  Signature -->______________________________________

Be sure your address matches the address that your credit card is billed to.

 

What is V Code?

V Code is the 3 digit number on the back for your credit card. The V code is located in the signature line and is
usually the last three numbers directly after your credit card number. ON American Express it may be on the front
above the card number on the right side.

Why V-Code?

This fraud protection checking system has been created so that if someone has possession of your credit card
numbers they also need to have possession of your card in order to know what your v-code numbers are.

Where is the V-Code located?

VISA, Mastercard, and Discover Card Requirements Card V-Code #
3-digit, non-embossed number printed on the signature panel on the back of the card immediately following the Visa card account number. This number is recorded as an additional security precaution
On American Express it may be four digits on the front
above the card number on the right side.

 

 

 

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