Alternate Order Form

Please only fill this out if you have been instructed to do so. Thanks!

Welcome! You should have been directed to this form to fill out some basic information for us to be able to process your order. Please Tell us a little about yourself!

Name(Required)
MM slash DD slash YYYY
Shipping Address(Required)
Consent(Required)
Please tell us how you found us!(Required)

Tell us About Your Doctor

You're Doctor's Name(Required)
Used for sending the results of your HOME data to them and formal communication from MyEYES.
Address
Specialty(Required)
What does your doctor specialize in?
This field is for validation purposes and should be left unchanged.

520 N Main Street, Suite C
Heber City, Utah 84032

Email info@myeyes.net (Preferred contact method)

Toll-free 1-833-5MY-EYES
(833-569-3937)

**Due to Unusual High Call Volumes, we ask you to be patient. Typically we are able to respond within 24-48 Hours. If you need immediate help, please send us an email**

 

Hours of Operation: M-F  MST 10am-4pm