Visit Request

Order Number

Date / Time

Date

Time

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Need help after your order? RDME5 Eyewear may provide a one-time complimentary visit for eligible customers. Please complete this form and include your order number so we can review your request and contact you to schedule.

Service Area Acknowledgment

I understand that complimentary visits are currently available only in the Las Vegas, Nevada area and are subject to scheduling availability.