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.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Best time to be reached (Order will be confirmed by phone)
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 your order.)
- Contact me by email when my contacts are ready to be picked up.
- Call me when my contacts are ready.
Shipping Option (if applicable)
Form of Payment
- I will pay when I pick up my contact lenses.
- Please call for my credit card information.
Questions or Comments