Anti-Fog Sprays & Wipes Order Form

Existing SafeVision clients receive approximately 15% off retail pricing when utilizing this form to purchase individual units and an additional 10% off when purchasing full cartons. Please be sure to include your shipping address if it’s different than your billing address. 

Bill to Account Number(Required)

PO Number

Company Name

Contact Name(Required)

Email(Required)

Phone

Fax

Billing Address(Required)

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Different Shipping Address

Ship to a different address

Shipping Company Name

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Shipping Address(Required)

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SV Antifog 30ml Spray KIT (60010007)

Individual ($13.95 ea.)

Quantity (34 or fewer)

Please enter a number less than or equal to 34.

Carton ($12.50 x 35= $437.50)

Quantity

SV Antifog 30ml Spray Bottle (60010001)

Individual ($11.95 ea.)

Quantity (59 or fewer)

Please enter a number less than or equal to 59.

Carton ($10.75 x 60 = $645)

Quantity

SV Antifog 15ml Dropper Bottle (60010003)

Individual ($9.95 ea)

Quantity (39 or fewer)

Please enter a number less than or equal to 39.

Carton ($8.95 x 40 = $358)

Quantity

SV Microfiber Cleaning Cloth (60010005)

Individual ($2.55 ea)

Quantity (59 or fewer)

Please enter a number less than or equal to 39.

Carton ($2.30 x 60 = $138)

Quantity

SV AntiFogDry Wipe 5 Pack (60010004)

Individual ($11.95 ea)

Quantity (39 or fewer)

Please enter a number less than or equal to 39.

Carton ($10.75 x 40 = $430)

Quantity

SV AntiFog Dry Wipe 100 Bulk (60010006)

100 Bulk ($190.95 for 1 or $170 for 2 or more)

Quantity

Special Instructions

• Pricing does not include shipping & tax
• SafeVision reserves the right to make changes to the product pricing at any time without notification
• PPE Distributor partners and Eye Care Professionals please contact your SafeVision sales rep or our customer service team to inquire about pricing
• Products will be shipped from: SafeVision by HOYA | 7000 Sunwood Dr NW, Ramsey, MN 55303