Rx Goggle Application/Order Form

Parents Click Here to Apply.

Doctors Offices Click Here to Fill Out Order Form.

When Order Forms are being filled out, we need both Offices and Parents to review the address information for accuracy BEFORE submitting order. We have been experiencing goggles being returned for inaccurate addresses. Our fiscal year runs from July 1st through June 30th. We are continuously taking Applications and Orders.

All parents must wait 12 full months before applying for another pair of goggles, even if a child’s prescription has changed, unless it is a major change. It is important to make sure child’s prescription is up to date when ordering. If there are no changes in prescription or size of goggles even after the 12 month time limit, please do not place on new order, thus allowing other children to participate in our program.

Paper vouchers are always valid. Participating Office List link is located on the Application Form and within the Goggle website. All parents should go to the website for answers to their questions. Thank you.