Order Form for In-Store Pickup

First Name:   

Last Name:   

Date of Birth:

Telephone Number:

R:L:B:
How many boxes would you like per eye? 1 2 3 4

Established patients only.  Prescription good for one year from the issue date.
A Lindsey Optical staff member will contact you when your order is ready for pick-up.  If you have not heard anything within 7 business days please contact the store.