Contact Lens Order Form

IF YOU ARE NOT A CURRENT PATIENT, PLEASE click here to fill out the Welcome Form.

Use the following form to order your contact lenses.

Order Contacts - Current Patients Only

*First Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip Code:

*Phone:

Email Address:

Best Time to be Reached (Order will be confirmed by phone):

I would like to order contact lenses for my:
Right Eye:
Left Eye:
Both Eyes:

How would you like to receive your contacts?

Please ship to my address above (Applicable shipping fees will be added to order).

Shipping Options:

Contact me by email when my contacts are ready to be picked up.

Call me when my contacts are ready.

Form of Payment: I will pay when I pick up contact lenses.
Please call for my credit card information.

Questions or Comments:

*Required Fields