Order Contact Lenses

Please complete the following and we will be happy to ship your lenses to you:

Patient's Name:

Date of Birth (mm/dd/yyyy):

Order:

lenses OR boxes (choose one)

Please bill this to the following credit card: (choose one)

Visa Master Card Discover

Card Number: Expiration Date:

Please confirm my order by (choose one):

e-mail

Confirm Email

phone (with area code)

Comments:

If there are any questions, we will notify you prior to filling your order.