Billing Information

Single/Family Online Sign-Up
Please complete the information below, so we will know where to send your starter kit. You will then be sent to the bank for credit card information.

Charge Amount: $19.95

Shipping information:

First Name:

Last Name:

Address:


City:

State:

Postal Code (5 digits - US or 6 digits - Canada):

Country:

Telephone: (ex. 555-555-5555)

Email Address:

For security purposes, you will now be transferred to our US Bank payment form for credit card processing.
Preferred Vision Care will never see or have access to your credit card number.
To protect your credit card, US Bank utilizes the Secure
Electronic Transaction (tm) specification.

Shipping information:

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