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CHS Eyeglass Payment Information Form

2. CHS Eyeglass Payment Information Form
   Please fill out the form below to pay for eyeglasses for a patient at Maricopa County Correctional Health Services.

   Please fill out the form below to pay for eyeglasses for a patient at Maricopa County Correctional Health Services.

4. Date:*
   Date:

   Today's Date

6. Requestor Information
   Please fill out below as the person paying for patient.

   Please fill out below as the person paying for patient.

8. First Name*

9. Last Name*

11. Phone Number*

12. Email Address*

14. Patient/Self Information
    Please fill out patient information below.

    Please fill out patient information below.

16. First Name*

17. Last Name*

19. Booking Number*

20. Date of Birth*
    Date of Birth

22. Payment Amount

24. Additional Information
    Within 24 hours of submitting this form, you will be sent an email with a transaction ID and an online payment link. You will be required to provide the transaction ID when submitting payment. An eye exam will be scheduled once payment is received.

    Within 24 hours of submitting this form, you will be sent an email with a transaction ID and an online payment link. You will be required to provide the transaction ID when submitting payment. An eye exam will be scheduled once payment is received.

26. Please NOTE:
    For safety concerns the patient will not be notified in advance of the appointment date/time.

    For safety concerns the patient will not be notified in advance of the appointment date/time.

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field