Application--Print this form, fill out, and mail to the address below

Dakota Eye Care
20% Discount Card Application
 

Name ___________________________________________		Date ________________________
Address ________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Date of Birth ___________	Day Phone _______________	Evening Phone ________________
Email address __________________________________________________________________

____   Individual $10.60 exam and eyewear only

____   Family ($15.90 for Head of Household) + ($5.30 for each dependent*)

____   Individual Laser Vision Correction $53.00 (individuals only - must be 18 or older)

Laser Vision Correction discount is $250 per eye on the surgery at Vance Thompson Vision, and $50 discount per eye on the post-op care with any Dakota Eye Care optometrist

*Dependents' First Names (spouse and each child)

for Family Discount Cards
1.__________________	2.__________________	3.__________________
4.__________________	5.__________________	6.__________________
7.__________________	8.__________________	9.__________________

Total: $ _________ (6% sales tax included in above prices)
 

Method of payment:____ Check    ____ Visa    ____ Mastercard
 

For a credit card order, please fill out the following
(also, email address is required above for a credit card order)

Credit Card Holder _______________________________________________________

Account # _______________________________________________________________

Exp. Date ___________ Security Code (3-4 digits, usually on back of card) ________

Signature _______________________________________________________________

Make check payable and mail to:
Dakota Eye Care
PO Box 91437
Sioux Falls SD 57109