REGLAZE ORDER FORM

1. PERSONAL DETAILS (please write in BLOCK CAPITALS)

Name: Landline:
Address: Mobile:
Email:

Postcode:
2. BRIEF DESCRIPTION OF YOUR FRAME (e.g. make, model, colour, etc.)

**Please note
NOTE:All that Are
Frames all frames areThe
Glazed At glazed
Ownersat Risk
the owner’s risk and
and We Cannot that Responsibility
Accept SpecsandGlasses.com
O For Damagewill accept
Caused no liability.
During Glazing. If we
We Will Return Anyfeel
Frames
that That
your We FeelisAre
frame Unsuitable
unsuitable forForreglazing
Glazing. then we will return it unglazed.**

3. MY FRAME TYPE IS… (choose one option only)

METAL NO COST
FULLY RIMMED
.

PLASTIC NO COST
SEMI-RIMLESS £10.00
RIMLESS £20.00

4. SELECT YOUR LENS TYPE (choose one option only)

DISTANCE £15.00
SINGLE VISION
READING £15.00
BIFOCAL (D28 segment) £25.00
VARIFOCAL £60.00
Please note: All lenses are made from CR39 plastic

5. OPTIONAL EXTRAS (All choices below are optional)

(choose one option only)
BROWN £50.00
PHOTOCHROMIC / REACTOLIGHTS
GREY £50.00
BROWN £50.00
POLARISED
GREY £50.00
(choose one option only)
THIN - 1.60 index (25% thinner) £40.00
ULTRA THIN - 1.67 index (40% thinner) £60.00
ULTRA ULTRA THIN - 1.74 index (50% thinner) £140.00
(you may tick more than one option)
UV400 COATING £10.00
SCRATCH RESISTANT COATING £10.00
ANTI-REFLECTION COATING £20.00

TINTS
£15.00
(choose one gradient and one colour only)
LIGHT BROWN
20% tint (Cosmetic) GREY
MEDIUM GREEN
50% tint BLUE
DARK RED
80% tint (Sunglasses) YELLOW
 ACCESSORIES
GLASSES CASE £1.50
MICROFIBRE CLEANING CLOTH £1.50
LENS CLEANING KIT (with cloth, spray & screwdriver) £3.00

7. PRESCRIPTION

SPHERE (SPH) CYLINDER (CYL) AXIS ADD PUPIL DISTANCE ADDITIONAL INFO
RIGHT EYE
LEFT EYE

8. TERMS AND CONDITIONS

I agreeI that
agreeI have read read
that I have and &understood the 'Terms
understood the Terms &&Conditions'
Conditionsof of sale
sale (located
which can beat www.specsandglasses.com).
found I am over
at www.onlineopticiansuk.com.
I am over 16 yrs old, not registered blind or partially blind, and my prescription is not
16 years old, not registered blind or partially blind, and my prescription is not over 2 years old. over 2 yrs old

9. TOTAL COST SUMMARY

Please use this chart below for your convenience to calculate the total price including delivery:

ITEM COST
FRAME TYPE: £ .
LENS TYPE: £ .
REACTOLIGHTS / POLAROIDS: £ .
THIN LENSES: £ .
COATINGS: £ .
TINT: £ .
ACCESSORIES: £ .
DELIVERY (via Registered Post): £ 3.95
TOTAL: £ .

11. PAYMENT DETAILS

I would like to pay with: Credit/Debit card

Cheque/Postal order (made payable to ‘Specs
Onlineand Glasses.com’)
Opticians UK
Once we receive
Credit/Debit your glasses, we will confirm the amount to be paid and send you a link to our website which will
card number:
allow you to pay for your reglaze using a pay pal account or a debit/credit card.
Issue number (if applicable):
Start date (if applicable): / (MM/YY)
Expiry date: / (MM/YY)
Security code: Please post your frame (Last 3 digits
securely on with
along signature strip)
your completed order form to:

Cardholder’s name:
Cardholder’s address (if UK,
Online Opticians different
8 ThefromChambers,
above): Town Hall Square, Great Harwood, Lancashire, BB6 7DD
Signature:

**We will always destroy your card details once we have processed your order**

Please post your frame securely along with your completed order form and payment to:

SPECS AND GLASSES.COM

Online Opticians UK, 8 The Chambers, Town Hall Square, Great Harwood, Lancashire, BB6 7DD
17 CHAYTOR TERRACE
FISHBURN
CLEVELAND
TS21 4DG