• Important Notice

  • If you are paying for any portion of your eyewear with a credit/debit card you must obtain a Secure Credit Card ID number to be used in place of the actual credit card number. This procedure is to protect your card number from theft or fraudulent use. Click here to obtain your Secure Credit Card ID number.

Client Account Number:   0005000
Secure Credit Card ID#:
Credit Card Type: VI,MC,AX,DI
Credit Card Expiration Date: MM/YY
Employee First Name:   *
Employee Last Name:   *
Supervisor/Contact Phone:   *
Employee Number:  
Department #:  
Requisition #:  
Employee Phone:  
(Optional: Automatically e-mail order form
to the above address)

To print a blank form please click the view e-form button.
3M is in the process of updating our prescription eyewear order forms. If your form appears in a different format be assured that nothing has changed with your program, just the form format has changed. This format change was implemented to ease the ordering process of eyewear. Please contact 3M customer service if you have any questions at 800.982.2828 or via email at srxcsr@mmm.com.