Miniviewer Order Form

Print This Form and Mail to:
The Low Vision Center of Fort Wayne
6208-B Constitution Drive
Fort Wayne, IN 46804
(260) 432-0575
Email: fortwayne@eyeassociates.com

Name  ________________________________________________  
 
Address _______________________________________________  
 
City, State, Zip __________________________________________  

Phone ________________________________________________  

Bus Phone  ____________________________________________  

Email Address __________________________________________  


Method of Payment:

[  ]  Certified Check    [  ] Money Order    [  ]  Personal Check (Allow adequate time for the check to clear.)  

[  ] Visa      [  ] MasterCard     [  ] Discover     [  ] American Express   

Credit Card Number __________________________________  

Expiration  Date  _____________________________________  

Name as it appears on card ________________________________________

Please send me:

Amount of Payment $ _________________________________

Quantity                       Item                                        Cost

 
Print This Form and Mail to:
The Low Vision Center of Fort Wayne
6208-B Constitution Drive
Fort Wayne , IN 46804
(260) 432-0575
Email: fortwayne@eyeassociates.com

Credit card orders can be taken via phone Tuesday through Friday at (260) 432-0575.