Order Request

Prescription Lens Order Request

Welcome to RDME5 Eyewear. Use this secure form to submit your prescription lens order request. Simply provide your prescription, select your preferred lens options, and complete the required information. If you need assistance at any stage of the ordering process, our licensed optician is available to provide personalized guidance and answer your questions.

Order Request Form

Name

First

Last

Date of Birth

MM/DD/YYYY

Phone number

GDPR Agreement Details

Address

Address Line 1

Address Line 2

City

State

Zip Code

How we can help?

Message / Order Details

Please include any frame, lens, prescription, or appointment details you would like us to review.

Upload Prescription (RX)

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Accepted file types: PDF, JPG, JPEG, and PNG. Maximum file size: 10 MB. Please make sure the image is clear and readable Please check prescription confirmation before uploading.

Prescription Confirmation

Prescription Confirmation

“I confirm and acknowledge that the prescription information I submitted is current, complete, and accurate to the best of my knowledge.”

Preferred Contact Method

Email
Phone
Text message

Best Time to Contact You