Request New Glasses

At InSight Eye Consultants, we understand just how common it is for glasses to become lost, misplaced, or damaged in various living facilities. That’s why we’ve made the replacement process as simple and stress-free as possible. Use the form below to request a new pair of glasses for your loved one, and our team will work quickly to get them a replacement.

Please Note: If we have not seen the patient before, an eye exam will be required prior to ordering glasses to ensure an accurate prescription. If the patient has previously received glasses from us, we can often reorder them right away if the same frame is reused. However, if a new frame is requested, the patient will be refit during our next visit to the facility before the glasses can be made.

Request For New Glasses

Patient's First name

Patient's Last Name

Patient's date of birth

POA's First Name

POA's Last Name

POA's Email

POA's Phone Number

POA's Address

POA's address is only needed if there is a co-pay for glasses. If insurance will not cover the patient's glasses in full, we will send an invoice to the address outlining the cost. Once payment is received we will order glasses.

Facility Patient Resides

Have we seen this patient before?

Yes

Note: If this is a new patient they will need to be seen for an exam before new glasses can be made.

If we have made the patients glasses before. Are you ok with us using the same frame style?

Yes: Use the same frame and order ASAP

No: Wait until the next clinic to have new frames measured.

Not Applicable

Note: Different frames require different measurements to ensure a patients glasses fit correctly and so they can see correctly out of the lenses. If you would like glasses ordered immediately we can do so by using the patients same frame and measurements. If a new frame is desired the patient will need remeasured at the our next clinic.

INSIGHT EYE CONSULTANTS TO NURSING FACILITIES

Request New Glasses

Request For New Glasses

Contact Information