MEMPHIS OPTICAL DISCOUNT VISION PLAN

Yes, I want to enroll in Memphis Optical’s Discount Vision Plan!

I am enrolling for a 1 year membership at $25.00

I am enrolling for a 2 year membership at $40.00

MEMBER INFORMATION
First Name   Last Name  
Address   E-Mail  
City   Daytime Phone  
State   Cell Phone  
Zip   Date of Birth  
SPOUSE INFORMATION
First Name

Date of Birth
Last Name    
DEPENDENT CHILDREN (up to 4, unmarried, 21 years of age & under, living in same household)
  First Name Last Name Date of Birth
Child 1
Child 2
Child 3
Child 4
PAYMENT OPTIONS
   
   
   
  I will mail a $25 or $40 check for the enrollment fee to:
Vision Program
Memphis Optical
4697 Poplar Avenue
Memphis, TN 38117
Print a copy of this form and mail it with your check. 
A membership card will be mailed to the address listed on your enrollment form.
 

When does coverage start? 
You can take advantage of Memphis Optical’s Discount Vision Plan as soon as we receive your enrollment form and $25 or $40 enrollment fee.