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Replacement Glasses Request

Use the form below to request replacement glasses for a child with a current vision prescription.

BEFORE YOU BEGIN

What to expect

1

A current prescription is required

Vision prescriptions expire after one year. If your child’s prescription has expired, they will need a new eye exam before receiving replacement glasses.

2

Outside prescriptions must be uploaded

If your child’s most recent exam was not provided by KVFL, upload a copy of the current prescription, including the PD measurement, using the form below.

3

Replacement frames may be different

Replacement frames may not match your child’s original selection. A frame will be selected from our available stock of free frames.

4

Please allow approximately two weeks

Replacement orders are placed at the end of each week and are typically ready about two weeks later. KVFL staff will contact you to arrange pickup when the glasses are ready.

Need a new eye exam? Please do not use this form to request an appointment or updated exam.

Complete the replacement request form below

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Did your child receive an eye exam from KVFL in the past year?

Yes - My child was seen on the KVFL Mobile Vision Clinic at their school.
Yes - My child attended a Summer Clinic with KVFL.
No - My child received an eye exam from another provider.

For reporting purposes, can you please tell us if your child's glasses were lost or broken?

Glasses are lost
Glasses are broken
Unknown

What school does your child currently attend? *

Please share the Building Name AND the School District to expedite your request.

If different, what school did your child attend last school year?

Please share the School District and the Building Name.

Student Name *

First

Last

Student Date of Birth *

Parent Name *

First

Last

Parent Email *

Parent Phone Number *

Please provide a detailed description of your child's previous frames:

Please include, Brand, Model #, Measurements, Color, etc.

Does your child have a current prescription from a different provider?

Yes
No

If your child's most recent eye exam was not with KVFL, please select YES and upload a copy of your child's prescription below. Prescriptions must be within one year to be valid. Please make sure your child's prescription includes a PD measurement.

Comments or Questions for KVFL Staff: *

Please provide any other details that would help us complete your order.

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