COMPLETE LIST OF SERVICES
COMPREHENSIVE EYE EXAMINATIONS
CONTACT LENSES
EYEGLASSES
LASER VISION CORRECTION
EYE INJURIES AND EMERGENCIES
DR. SHARI JURGENSEN
DR. LETICIA DEMAIO
DR. KEVIN HARTE
(in memory of) DR. RAYMOND JURGENSEN
CONTACT LENS ORDERS
Patient Information
First Name*
Last Name*
Address 1*
Address 2
City*
State*
Zip Code*
Daytime Phone*
Email Address*
Evening Phone
Prescription
On File
Will fax to 630.629.1941
Call My Doctor
Right Eye Number of Boxes*
-- SELECT BOXES --
One
Two
Three
Four
Left Eye Number of Boxes*
-- SELECT BOXES --
One
Two
Three
Four
Billing Information
Same as Patient
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Daytime Phone
Email Address
Evening Phone
Shipping Information
Same as Billing
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Daytime Phone
Email Address
Evening Phone
Delivery Type
-- SELECT DELIVERY --
Please ship order
Pick up at the office
Payment Method
-- SELECT PAYMENT METHOD --
Have staff contact me
Bill Card on File (re-order)
Notes