Prescription Glasses Order Form

Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

Phone *

Do you have current glasses prescription? *

Prescription date must be within 1 year

Are you Dr. Allyson Tang Optometrist's patient? *

Purchased glasses previously with Dr. Allyson Tang Optometrist or other IPURLE store locations? *

If yes, please provide us the location *

What type of glasses you interested? *

Please specify the frame model number:

What type of lens are you looking for? *

If choose other, please specify the type of lens:

How would you like to receive your order? *

Please specify pick up location below: *

Additional Comments/Special Requests:

Please provide us more information if possible, Thank you!

Please upload current glasses prescription *

Click or drag a file to this area to upload.