Contact Lens Order Form

It is necessary to have a valid contact lens prescription on file at our office.

Indicates required information.

Step 1: Contact Info

First Name:
Last Name:
Date of Birth:
Phone:
Cell Phone:
E-Mail:

Step 2: Product Info

Quantity (in number of boxes):
Right eye	Left eye

Step 3: Comments

Step 4: Payment Options

Once your online request has been received we will send an invoice to the email address you entered above. You will be able to confirm your delivery address and select one of the following payment options at that time. If you have insurance benefits and would like to have them billed, please indicate this in the comments box above.

There is a $5 shipping fee for all orders. This fee is not covered by insurance.

Step 5: Finalize

	Which day comes before saturday?

We value your privacy. Your e-mail address will not be given/sold to third parties and will only be used to respond to this inquiry and future correspondences.