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Purchase Form
Macular Degeneration 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
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.
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| Name |
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| Address |
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| Address |
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| City,
State, Zip |
| Email |
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| Re-enter
Email |
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| Phone |
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| 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.
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Where is the V-Code located? |
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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 |
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On American Express it
may be four digits on the front above the card number on the right side. |
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