Visit Request

Mobile Optical Visit Request

Thank you for choosing RDME5 Eyewear. Use this form to request a mobile optical visit for personalized prescription lens assistance. Whether you need help selecting lenses, taking measurements, or placing an order, our licensed optician will contact you to arrange a convenient appointment.

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.